The Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/aviation.aspx. The Aircraft Accident Report number is NTSB/AAR-20/02. On February 23, 2019, at 1239 central standard time, Atlas Air Inc. flight 3591, a Boeing 767-375BCF, N1217A, was destroyed after it rapidly descended from an altitude of about 6,000 ft mean sea level and crashed into a shallow, muddy marsh area of Trinity Bay, Texas, about 41 miles east-southeast of George Bush Intercontinental/Houston Airport (IAH), Houston, Texas. The captain, first officer, and a nonrevenue pilot riding in the jumpseat died. Atlas operated the airplane as a Title 14 Code of Federal Regulations Part 121 domestic cargo flight for Amazon.com Services LLC, and an instrument flight rules flight plan was filed. The flight departed from Miami International Airport, Miami, Florida, about 1033 (1133 eastern standard time) and was destined for IAH.
The inappropriate response by the first officer as the pilot flying to an inadvertent activation of the go-around mode, which led to his spatial disorientation and nose-down control inputs that placed the airplane in a steep descent from which the crew did not recover. Contributing to the accident was the captain's failure to adequately monitor the airplane's flightpath and assume positive control of the airplane to effectively intervene. Also contributing were systemic deficiencies in the aviation industry's selection and performance measurement practices, which failed to address the first officer's aptitude-related deficiencies and maladaptive stress response. Also contributing to the accident was the Federal Aviation Administration's failure to implement the pilot records database in a sufficiently robust and timely manner.
Boeing 767-300F · N1217A — 427,521 samples, 109 parameters, 10:27:09.1 to 12:39:02.9.
| Parameter | Max | at | Min | at | Final | at |
|---|---|---|---|---|---|---|
| Pressure altitude ft | 40,036.0 | 11:56:40.5 | -216.0 | 10:29:27.5 | 224.0 | 12:39:02.5 |
| Radio altitude ft | 5,500.0 | 10:34:52.2 | -8.0 | 10:27:10.2 | 305.0 | 12:39:02.2 |
| Computed airspeed kts | 433.5 | 12:39:02.3 | 0.0 | 10:27:10.3 | 433.5 | 12:39:02.3 |
| Ground speed kts | 486.0 | 10:49:45.6 | 0.0 | 10:29:42.6 | 385.0 | 12:39:02.6 |
| Pitch attitude deg | 19.0 | 10:33:36.7 | -49.6 | 12:38:57.7 | -16.2 | 12:39:02.7 |
| Roll attitude deg | 26.4 | 12:36:47.8 | -27.1 | 10:35:13.8 | -4.6 | 12:39:02.8 |
| Vertical acceleration g | 4.3 | 12:39:00.6 | -1.0 | 12:38:50.4 | 4.0 | 12:39:02.9 |
| Engine 1 N1 %RPM | 111.0 | 12:38:42.7 | 26.0 | 10:27:09.7 | 66.0 | 12:39:02.7 |
| Engine 2 N1 %RPM | 111.0 | 12:38:43.2 | 25.0 | 10:27:12.2 | 68.0 | 12:39:02.2 |
| Magnetic heading deg | 359.6 | 10:35:57.8 | 0.0 | 10:36:26.8 | 267.2 | 12:39:02.8 |
| Time | Event | Page |
|---|---|---|
| 10:33 | Aircraft departed and climbed for about 20 minutes to a cruise altitude of 40,000 ft; center autopilot and autothrottle engaged shortly after takeoff and remained engaged for the remainder of the flight | 5 |
| 12:25 | Initial descent out of 34,000 ft began; autoflight systems in LNAV/VNAV modes | 5 |
| 12:36:27 | Autopilot lateral mode changed from LNAV to Heading Select; immediately before reaching 10,000 ft the captain's radio mic was keyed | 5 |
| 12:36:35 | Aircraft reached 10,000 ft | 5 |
| about 12:37:00 | Autopilot vertical mode changed from VNAV to Flight Level Change; MCP altitude selection changed from 7,000 ft to 3,000 ft; speedbrake handle extended and rate of descent increased | 5 |
| 12:38:04 | Flaps selected from up to position 1; autoflight go-around modes armed as flaps began to move | 5 |
| 12:38:26 | At about 6,500 ft, triaxial acceleration magnitudes increased, consistent with entering light to moderate turbulence | 5 |
| 12:38:31 | Autoflight system entered go-around mode; engines began advancing to go-around thrust; control column moved slightly aft, elevator deflected up, pitch began to increase, altitude stopped descending and began to climb | 5 |
| 12:38:37 | Speedbrake handle retracted; engines approached commanded go-around power settings | 5 |
| 12:38:40 | Master Caution and Autopilot Caution recorded; control column had moved to be deflected forward, pitch decreasing, airspeed accelerating rapidly from 240 knots; autoflight remained in go-around modes; shallow climb briefly then rapid descent; column remained forward for the next 10 seconds | 5 |
| 12:38:46 | Throttles brought to idle for about 2 seconds then re-advanced to previous power setting; pitch rapidly decreasing; vertical g negative for nearly 11 seconds | 5 |
| 12:38:47 | Split between left and right elevators noted, 2 to 7 degrees, until 12:38:57 | 5 |
| 12:38:55 | Overspeed and Master Warning alerts recorded with airspeed increasing beyond 350 knots | 6 |
| 12:38:57 | Altitude crossed through 3,000 ft; autothrottle switched out of go-around mode and engine TRA began to decrease | 6 |
| 12:38:58 | At about 2,000 ft the control column moved to the aft stop until the end of the recording; pitch about 50 degrees nose down | 6 |
| 12:39:03 | End of recording; vertical acceleration went from 0 g to 4.2 g; pitch increased rapidly to final recorded position of 16 degrees nose down | 6 |
481 transcribed utterances from 11:57:59.1 to 12:39:02.0, 16 sources. Final entries:
| 12:38:58.9 | CAM | [Sound of longer duration pulse tone about 1000 Hz, similar to Siren. Group could not determine if audible sounds lasted until end of recording.] 6 |
| 12:38:59.4 | CAM-3 | * pull up. [Shouted.] |
| 12:39:00.9 | HOT-2 | [Unintelligible shout.] |
| 12:39:02.0 | HOT-? | (oh God). [Shouted.] |
| 12:39:02.0 | HOT-2 | Lord * * you have my soul. [Shouted.] |
Docket: data.ntsb.gov/Docket/?NTSBNumber=DCA19MA086. This brief is an analytical aid assembled from public records; it is not an investigative finding.