20 Seconds to Save It: How an Impulsive Pilot Caused a Fatal Crash Revised 

My friend was on the jumpseat. We were in the same newhire class at Mesa. Sean was a good guy. The FO that crashed it was known to be argumentative when people tried to give him advice. It's a small industry.

I've been in complete IFR several times where I would swear that I was nose up 30 degrees about to stall. I never got nervous about it, I just noted the effect as fascinating, and stayed on my instruments like a hawk.

NTSB doesn’t pull any punches here, as it should be.

"You probably remember this from your instrument training." Me, who's never flown an airplane: Ah, yes, of course.

Im not even a pilot but I always remember something my pilot friend told me "Trust your instruments"

If only there was some sort of visual aid to tell him what the plane's actual pitch was

out of all the pilots that were laid off, they didnt choose this guy....

gotta respect the flawless logic of "I dont know what to do, but if I press enough buttons it will work out"

We have the same problem in medicine. I’m an anesthesiologist and know which surgeons and anesthesiologists I would trust my family members with, and just as importantly, who to avoid. Thanks for another sobering episode.

FO should have never been in that Aircraft.

46 degrees pitch down. I'm asking the other pilots here, has anyone ever seen another pilot "accidentally" pitch down 46 degrees, somatogravic illusion or not?

Over 25 yrs in aviation and I flew with a lot of people like this. Unfortunately, many were mercy passed when they should have washed out.

Air speed good Altitude good Horizon indicator good Jules Aska: we stalling

I was a flight operations manager and check pilot in Canada. We were not allowed to share information about pilots to other companies due to privacy regulations. We devised code words to warn other airlines about bad pilots if they inquired about our experience. Still likely breaking privacy laws but hopefully kept people alive.

So the FO was basically a human MCAS.

Somatogravic disorientation is real and the only way to really experience it is to get into real IMC, where there's only you and your instruments and no autopilot. I was surprised how quickly it set in during my first acutal IMC flight during instrument training. Went up on a 300 foot drizzling morning and immediately started veering off course once we hit the clouds. Got on the instruments and got back on course--stayed in it for about two hours and had to take a nap after I got done.

As an industry captain this makes me nauseous. We know when we can trust the guy/gal next to us or not. I welcome a little more scrutiny in the pilot selection process. Farming out selection is a bean counter fail that unfortunately has led to a fatalities.

"Weak piloting skills?" He didn't have any. I did have to avert my eyes. The stupidity was overwhelming. Shades of Air France 447. That idiot did the opposite but with same results.

Even if the plane was stalling, the way to recover is not to shove the nose down 50 degrees. The FO was so lucky he had such a nice cargo job, he failed way too many check rides and couldn’t handle any stressful situation.

Great video, thanks AVWeb and Paul. There's gold in the last 30 seconds, a simple assessment to solve the riddle of am I stalling or am I plunging downward nose first. Assuming instruments are working, in the case of spatial disorientation, following those very simple instructions can right the ship and keep it from going from bad to worse. Air France 447 had some very experienced pilots and flight engineers onboard, and yet they managed to pancake an otherwise perfectly functioning A330 because of partial instrument failure (pitot tube ice crystals) and lack of external references. That still bothers me to this day, that such a skilled group couldn't solve the problem and stalled all the way from cruise altitude. In any case, in a situation where you sense a stall at low altitude, like this accident case, reacting immediately is the right thing to do. But that reaction must include reading the actual instruments, not just the feels of the seat. RIP for the three crew, and thank god they hit an unpopulated area on impact.

IFR qualified FO doesn’t know how to use instruments 🤔

I first experienced it in IFR training during a missed approach to minimums. I started the climb and turn, then bent over to get an approach chart. When my head came back up again it was there! The plane felt like it was in a 45 degree bank, when the attitude indicator said level. So to induce it reliably, don't just have the student hang their head, have them bend over and touch the floor then bend back up again, all while in a turn.

Excellent job Paul! This is easily the best and most comprehensive summary I have seen regarding this incident. I appreciate your diligence in presenting the information with supporting video clips and graphics. Well done and thank you!

"It could be a smoking crater in your future". I like this guy.

33 years of flying. 28 of them Airline Transport rated. 20 yrs at a major North American Airline. I have seen people in positions they do not possess the skills for. The reasons for this have been many: - Didn't want to fire them, felt bad for their family - Hired foreign nationals to keep the contract. - Hired women to meet anti- discrimination (* there are women pilots equal to or better than men just not in this case) - Believed the odds of a failure that would require high skill were "statistically improbable" - a quote from a DFO - The only pilots they could hire were the ones other airlines wouldn't. More often than not it was about money. The cost of replacing or retraining or the cost of hiring the proper experience level was the primary concern. Don't kid yourself, in today's world of reliable automation, many airlines view pilots as something akin to perfunctory systems monitors and want to pay them accordingly. So they will underpay and under-train under-qualified people then take no responsibility when s**t hits the fan.

"We're stalling! I going to not look at my instruments during IFR, and instead initiate a kinetic strike on the ground below!"

I thought moving the requirement from 250 hours to over 1000 hours to qualify as a first officer was supposed to solve this type of accident. I think what it did was reduce the number of qualified pilots with demonstrated skill who otherwise might have been available for Atlas to hire.

I experienced this illusion during my instrument training in actual IMC. Felt like I was pitched straight up. Instruments were rock solid, and all indicated I was straight and level and on course. It only lasted a few seconds to maybe a minute, but I can see how it could easily be misinterpreted. Trust your instruments.

So, basically, the FO resorted to flying by the seat of his pants.

Thank you sir for another interesting video. I am not in aviation, but I find it fascinating.

Thank you! Your classes are always on point and enlightening!

Great video. Great talking and explaining skills, and great audiovisual support. Thanks and good day!

“My Airplane!!” “Your Airplane!!” I guess that’s something that should never be taken lightly. Sad.

I’m a nurse, never a pilot but I don’t understand why he kept a license when he could kill someone by panicking.

Fantastic video. Love the analysis and very clear in your presentation

As a huge aviation fan, I am happy YT suggested a video that made me discovered your channel today. I've watched a couple of your latest video, and I love your content. No nonsense reporting, and good insights, just like blancolirio. Today is a good day. :)

Great job yet again!

Thank you for issuing a correction to the original video. There are too many times incorrect information is posted and left up in perpetuity with nothing more than a footnote, or worse, nothing at all, to indicate any of the information may be incorrect.

Great video, Paul!

Great video thank you so much for posting

I LOVE Paul’s question, “How did it get this far?”. I can tell you from experience how. If you’re a woman or a minority an airline will do ANYTHING to get you through training and onto the line. They are terrified of being sued by a woman or minority for discrimination. I’ve personally witnessed this at Mesa airlines while working in the training department. There was a female pilot upgrading to captain in the ERJ that had no business being a pilot PERIOD. She was pushed through training and later CRASHED an ERJ in Roanoke VA. She landed the airplane in a full stall and hit the tail before the gear and tore a hole in the airplane. Then she went to the hotel and neither she nor her female first officer, who was also a flaming idiot reported the damage to the aircraft. The captain was fired but her equally untrustworthy first officer kept her job. She’s out there to this day flying people around. That’s how it gets this far Paul. Political correctness and spineless people get other people killed. I’ve flown the line with numerous female pilots. Some were great pilots. Others had zero business driving a car much less flying. I flew with a female first officer in the Beech 1900D that nearly crashed the airplane landing in Philadelphia on a clear day with calm winds. I discussed her poor airmanship with a check airman and the chief pilot and they refused to do anything about it. I was paired with her for an entire bid period and I wouldn’t let her fly the plane. She was barely able to operate the radios. I was basically single pilot for a month in the northeast winter with no autopilot and an incompetent FO. And this woman had an ATP and was at her third airline. It is what it is. I’m out of the flying business now and if I need to go anywhere I drive. People would shit if they knew what was going on in cockpits.

This is why I fear flying. The airline industry is incompetent. This is not the fault of the FO, this is 100% the fault of the people who allowed him to proceed through training when it was obvious he didnt have the IQ or nerve required.

Best coverage ever! The kind of analytics I admire in a report. Way to go! I’m a retired CP and Instructor from the seventies... this Atlas air disaster is why I am no longer confident in commercial travel. Have pilots today forgotten to Aviate first! Our problems as pilots needs to be checked and made known and revised constantly. In this case the plane would have probably had a better outcome on it’s own if both pilots would have left the cockpit entirely, letting the plane talk to ATC fully automated haha lol... maybe one day eh, long after I’m gone!😇

The FAA should be abolished and the NTSB should be put in charge of setting regulations. The FAA's mandate to promote aviation and promote safety are in direct conflict with each other.

Wow..what a crazy, sad....yet very interesting story.

Bertorelli. 👏🏼👏🏼👏🏼👏🏼👏🏼👏🏼👏🏼

This is a wonderful video on aviation safety. Loved it.

Great thorough presentation.

God forbid he looked at the instruments.

So blame the Capt. for not doing the "fully certified" FO's job while trying to do his own. Instructors at all levels have been killed by their students who rapidly put an aircraft into a condition that the instructor could not respond early enough to recover the students mistake. This FO wasn't a student! He was a certified commercial pilot! If the Capt.'s are going to be held "ultimately responsible" then they should have the right by law to pick a second in command they can trust.

Another wonderful, fact filled video. Thanks for all you do for so many and may you continue doing so in the best of health. From a NEW SUBSCRIBER.

"Flaps 1" 40 miles from field is my first clue someone is not comfortable with aircraft...and elevates my "get ready" level, and prompts me to ask "why configuring this far out?"(Unless you're being "slam-dunked" into a field due to a runway change)

I think that a good idea would not be this merit and so called "experience" based stuff, but pilot selection based on things like quotas, gender, sexual preferences and skin colour. That's happening in companies all over the place with _excellent_ results. Also in policing and the military. I think universities have picked up on the theme as well. The flight industry should really look into this new way of hiring to ensure everyone gets a fair go.

Paul Bertorelli opened a wasp's nest on this video. Having read most of the 340 replies, I see two separate issues being responded to. As a former check airman, I was deeply interested in the motivation and methodology of the cockpit actions and how we could learn from it. The other issue is diversity. I can't seem to get the issue focused on the "why and how", so we can learn the "stick and throttle" responses to avoid it in the future, as the issue has been captured by the "He shouldn't have been there" group. This may have to be split into two separate discussions to learn from each one. As of now it is a garbled mess. I believe once a crew is formed from whatever the source, that it is the captain's responsibility to make it work. PIC is just that, PILOT IN COMMAND. Underline COMMAND. That command starts upon introductory handshake and doesn't end until engine shutdown and out the jetway or air stairs. I believe this captain was a weak commander and wasn't watching the FO close enough. Crews know about each other. The FO had a history and bore watching. The responsibility of this captain's command was to be prepared for the FO's actions. The pre-start brief should have had the jump seater included in the brief. All the diversity chatter stops at the cockpit door and the crew fly as a crew from there. I still want to know why the captain or FO didn't pull the power back once the nose was down as that would have give them more time and physics to save the a/c. Can we talk about flying and leave the sociology for another discussion?

great review, thank you.

20:35 this is so well put.

They made excuses for his behavior... And we get to see the end result.

When training for my PPL, my instructor would have me look down at my lap wearing the hood, do some steep turns, then put the plane in an unusual attitude. Then he would tell me to look up (at the instruments, not out the window) and recover the aircraft. The steep turns really help with inducing vertigo.

Excellent reviewof a totally frightening situation. How he managed to get into a right seat is mind boggling.

This reminds me of the Teterboro crash where the First Officer failed one or more check rides and wasn't even supposed to be flying the plane.

"...there could be a smoking crater in your future..." Almost a bit of 'humor' there but it seems to drive the point home very bluntly and accurately.

Looking at the training history, unfortunately you had a real life Jar Jar Binks in the cockpit, with tragic consequences. There needs to be a centralised training database / blockchain project to make training records visible and easy to see - preferably at international level via ICAO guidance. Unfortunately some people are just not skilled enough to competently fly a jet (I definitely consider myself one of them) and should not be let loose on a commercial aircraft.

How in the world was this FO even a FO??? How was he even allowed any where near the cockpit of any aircraft to begin with given his training and in flight history?!? Makes you wonder how many others have faked they're way into an airplane FO seat. Was only tiny fragments of that plane left scattered all over the mud, well he succeeded in the inevitable.

Superb explanation and presentation!

Good heavens: "..pushing a lot of buttons without thinking about what he was pushing..." sounds too much like Homer Simpson at the nuclear power plant. There is too much real life following satire these days. It's bad enough when it happens in politics, but Lord is it sad when real life following satire results in such tragedies.

And people get mad in call of duty when your team mate gets you killed, dayum...

"...there could be a smoking crater in your future." Pretty much sums it up.

As a CFI my dad had one student who had been working on his pilot's license for an unusually long time. My dad was this guy's 4th IP. The student was a lot like this guy, taking impulsive, inappropriate actions. My dad tried to break this habit but in the end told the guy he was no longer going to be teaching him, and he strongly suggested he quit taking lessons. Another student he was teaching accidently performed a snap roll rather than a side slip as he intended. The student was startled and let the controls go half way through the snap roll. Now they were inverted at low speed and very close to the ground. My dad was able to recover but it was a very close call, The tail of the plane was green with grass stains and wheat was tangled in the landing gear. My dad continued teaching this guy after the near crash. I can't imagine how bad the student he refused to teach was.

One more ATP that can’t fly an airplane. Go figure. Pitch plus power equals performance. And hey, guess what...it’s never good when the attitude indicator is all green with no more blue side to keep up, and the altimeter is unwinding like an elevator in the Empire State Building with broken cables.

"Homo the Sap". Gotta write that one down. Took me a second to get it.

"...There could be a smoking crater in your future." How does Paul Bertorelli prevent icing conditions? By having absolutely no chill.

Excellent videos. The Kobe Bryant was educational and perfect esp with its effects/graphics.

Please, people..>TRUST YOUR INSTRUMENTS.

Big fan of your videos Paul! On the Blancolirio channel, Juan has a great video on how it’s not uncommon for a captain PM when reaching around the throttles to change the flap handle (flaps 1) in turbulence to hit the go around button with their watch. He’s seen it happen from the jump seat and the pilots did not notice it. Also he talks about that the pilots had so much opposite yoke in put that it physically separated the connected yokes. Could not the pilots feel the opposite force of the other pilot and say something?

Highly interesting explanation of why the FO perceived a stall due to a speed increase. I learned a new word: somotographic illusio. Thanks!

There is an "old procedure" that instructors would say to students: "don't do nothing, do SOMETHING, even if it is wrong". When I was learning to fly in the 1970s, I was told that by several "old time" instructors. ABSOLUTELY WRONG "procedure"!!!

"There could be a smoking crater in your future." That is a sobering warning if there ever was one.

Atlas failed the pilot and FO by not conducting good enough testing. The NTSB presentation shows that the FO should not have been in that plane. Atlas should be taking a long hard look at their hiring/training/ and testing procedures after this. Blaming this accident on "human error" is quite a stretch considering how unqualified the FO was. Hindsight bias sure is a beautiful thing.

Holy ship! Reminds me of a virtual air race from Russia across the Baltics to Finland... P-39D was the plane, the weather stunk, looking out was grey skies and black seas. The Instruments were my only Friends for over an hour Instrument flying has never been fun to me. Sad to hear this man listened to his gut feelings and did not check or his his virtual horizon. 46 degrees. in a 767. Mad. May they rest in peace.

Somatogravic illusion seems to be the new go to explanation.

Lack of flying skills for the FO and above all, a personality unfit for this job - as tragically demonstrated by his actions leading to the accident. Flying is one of these occupations that don't suffer impulsivity and irrationality. The captain had very little time to recognise the extremely dynamic and shocking situation and I'm afraid very few of us might possibly have reacted in time. It's not fair in my opinion to count 20s of available time for him to intervene because he was also talking to ATC and extending the flaps. From the moment the situation clearly became worrying to the accident, things developed shockingly fast. The FO WAS AN ACCIDENT WAITING TO HAPPEN. That he was even considered for upgrade with the previous airline is beyond me.

20:51 you could be a smoking crater in your future - that hit different

Somatogravic Illusions vs. possible instrument failures, sometimes so difficult to decide. If you are feeling dizzy go by the instruments. Both things occurring at the same time is highly unlikely. You are the broken thing! We've all been there. I do feel that observing a 30 degree plus nose down attitude would not warrant forcing the nose down further. (sic) Consistently practice hand flying. When in doubt, hit the AP disconnect and fly. Getting rid of the FD command bars is paramount as they can do as much to disorient as a failed instrument. The GA button is only useful in NORMAL situations. Maintain not only stabilized approaches but also stabilized cruise, climb and descent profiles. If you do, any anomalies will be VERY apparent when you disconnect the AP. I had to bust a candidate for a cargo company I was with. He was a very congenial person and quite likable. However, he was elderly, low time and made way to many innocent mistakes that could be deadly. I caught a very large load of grief from my higher ups (Do you realize how much $ we have invested here?). The candidate left us but contacted me afterwards to thank me for MY judgement and to say that I was right. He admitted he'd had the same problem with several other companies and it was time to give it up.

Great work from all the many people working so hard to find out what caused this. What was it?

Somatogravic illusion is deadly, we had several instances in the last few years. However, even instrument failures can lead to a similar inflight upset. For example West Air Sweden 294 needed just 80 seconds from FL330 to ground impact due to a very hasty recovery attempt based on attitude data presented by a malfunctioning IRS on the captains PFD.

Man I wouldn’t trust most of my coworkers to make my coffee much less pilot a airplane I’m in.

Hi : thank you for the video

Well said at the end. “...but if you never do it, there could be a smoking crater in your future.”

I cannot understand why the NTSB and Paul did not discuss the presence (or lack of) of the captain. Why the captain did not intervene and reduce power is a puzzle to me. Like the two 737 Max fatal accidents, I cannot understand why thrust was not reduced until impact. That is worth studying as an industry training problem. The PIC is responsible and seems to be left out in this discussion.

This accident showcases a failure of the system at all levels. And I’m not just talking about the piloting perspective. The aviation system in and of itself is extremely safe, and there are lots of safeguards and redundancy built in to ensure the bad pilots wash out and the good ones get to continue flying. However, the system is only effective and reliable if the “gatekeepers” to career advancement (i.e, instructors, examiners, and hiring/HR departments) and fellow pilots speak up when they are concerned about the proficiency of a co-worker. This first officer - Conrad Aska - simply put, had no business flying airplanes of any size for a living. Poor ADM and flying skills do not manifest themselves in large jets alone, but rather at all levels of flying. This was demonstrated by the FO’s poor training record. Multiple primary training and even Part 121 checkride failures. Many complaints from fellow pilots. By the time Aska got to Atlas and was flying 767s, everyone knew he did not have the “right stuff” - and yet he still was able to get the job and continue flying. Why is that? He was argumentative, impulsive, a “button masher,” and had multiple checkride failures. I think that at the end of the day, many of the gatekeepers are just afraid or hesitant to do their jobs properly because it’s an uncomfortable spot to be in. Nobody likes to end someone else’s career. It’s much easier to lie to yourself and write off a student’s poor performance as a bad day, or something they’ll be able to be trained up on. It feels bad to have to confront someone for their poor performance - especially someone as argumentative as Aska - but to do anything else, as we can see from this accident, is criminally unacceptable. Yes, Conrad Aska was definitely at fault for this accident. But an entire system built around training to proficiency and bandaging up the performance of bad pilots, while examiners hesitate to just call a spade a spade and toss out the candidates who just aren’t meant to be pilots, is just as culpable for these three lives ending prematurely. Repeated checkride failures and the company’s knowledge of his awful piloting reputation are worthless if nobody acts on them and fires him. There is a massive demand for pilots (or at least was, pre-COVID) that should return once the worldwide economy has recovered. The training system will be in full-on push pilots through to staff flights mode. Hopefully they will recognize some of the issues I listed above and fix them. If history is any indicator, I doubt anything will have changed though. Stay vigilant out there.

"You probably remember this from your instrument training, and maybe even your basic flight training." Me who has never flown an aircraft: "Yes, of course, continue...."

The fact that this video had 128k + views on a channel with 158k subscribers shows how interested those in the aviation community are to learn about the causes of crashes, hopefully with the intent on preventing the next one. It would be nice if the FAA would show the same amount of interest and dedication towards creating and implementing a mandated, shareable database to track pilot performance so that airlines can make informed choices about who they hire. This is going to be especially critical after COVID restrictions ease and airlines start to bring back furloughed pilots and hiring new ones. This crash reminded me of the Asiana Flight 214 crash at San Francisco. A pilot with poor basic flying skills in control of a multi-hundred million dollar aircraft causing a crash that never should have happened.

The first officer should've NEVER been in that cockpit but sadly we are too politically-correct to divulge the flawed hiring practices that led to him being in that seat because of his race. The fact that many of you on this board have resorted to predictably calling people 'racist' for this perspective is actually making my point.

Bit of switch mode power supply in there. Happy to help consult on improving audio.

Imagine being that first officers son and hearing this. Damn I don't appreciate my average never tragically messed up father enough

This is horrifying

Anyone surprised that the airlines he was at were Mesa, Wisconsin, or Atlas? Not one interviewer asked if he busted a check?

Imagine being stuck with this unqualified FO/pilot sad

This is where Affirmative Action stops and skill & knowledge really matters.

I'm no pilot but I would think a quick glance at your airspeed showing you're going way way over your stall speed would be enough to make you pull out of your dive.