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Cases › DCA19MA086 · Major investigation · Class 1

Boeing 767Atlas Air

Trinity Bay, TX, USA · 2019-02-23·N1217A

3
fatal
0
serious
Fatal
highest injury
Destroyed
damage

What happened

NTSB summary, verbatim

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.

Photographs

1the aircraft, and what the investigators found
The aircraft before the accident
N1217A MIA
K.Tomoaki · CC BY-SA 4.0 · Wikimedia Commons

Probable cause

the Board's determination
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.

Occurrence sequence

1 stepsNTSB coding · CICTT taxonomy
  1. 1 · Enroute-descent
    Loss of control in flight
    defining event

Findings

5 causal · 7 contributing
  • CAUSE
    Organizational issues › Support/oversight/monitoring › Documentation/record keeping › Personnel records — Not specified
  • CAUSE
    Organizational issues › Support/oversight/monitoring › Documentation/record keeping › Personnel records — FAA/Regulator
  • CAUSE
    Aircraft › Aircraft systems › Auto flight system — Unintentional use/operation
  • CAUSE
    Personnel issues › Task performance › Use of equip/info › Use of automation — Copilot
  • CAUSE
    Personnel issues › Action/decision › Action › Incorrect action performance — Copilot
  • FACTOR
    Personnel issues › Experience/knowledge › Experience/qualifications › Qualification/certification — Copilot
  • FACTOR
    Personnel issues › Psychological › Perception/orientation/illusion — Copilot
  • FACTOR
    Personnel issues › Experience/knowledge › (general) — Copilot
  • FACTOR
    Personnel issues › Psychological › Attention/monitoring › Attention — Pilot
  • FACTOR
    Personnel issues › Psychological › Personality/attitude › Personality — Copilot
  • FACTOR
    Aircraft › Aircraft systems › Indicating/recording systems › Data recorders (flight/maint) — Design
  • FACTOR
    Aircraft › Aircraft systems › Auto flight system — Design

Safety recommendations

6 issuedwhat changed because of this accident
  • A-20-033Closed - Acceptable ActionCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Inform Title 14 Code of Federal Regulations Part 119 certificate holders, air tour operators, fractional ownership programs, corporate flight departments, and governmental entities conducting public aircraft operations about the hiring process vulnerabilities identified in this accident, and revise Advisory Circular 120-68H, “Pilot Records Improvement Act and Pilot Records Database,” to emphasize that operators should include flight operations subject matter experts early in the records review process and ensure that significant training issues are identified and fully evaluated.

  • A-20-034Closed - Acceptable ActionCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Implement the pilot records database and ensure that it includes all industry records for all training started by a pilot as part of the employment process for any Title 14 Code of Federal Regulations Part 119 certificate holder, air tour operator, fractional ownership program, corporate flight department, or governmental entity conducting public aircraft operations regardless of the pilot’s employment status and whether the training was completed.

  • A-20-035Closed - Unacceptable ActionCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Ensure that industry records maintained in the pilot records database are searchable by a pilot’s certificate number to enable a hiring operator to obtain all background records for a pilot reported by all previous employers.

  • A-20-036Closed - Unacceptable ActionCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Establish a confidential voluntary data clearinghouse of deidentified pilot selection data that can be used to conduct studies useful for identifying effective, scientifically based pilot selection strategies. This program should be modeled after programs like Aviation Safety Information and Analysis Sharing and Flight Operations Quality Assurance.

  • A-20-037Closed - Acceptable ActionCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Issue a safety alert for operators to inform pilots and operators of Boeing 767- and 757-series airplanes about the circumstances of this accident and alert them that, due to the close proximity of the speedbrake lever to the left go-around mode switch, it is possible to inadvertently activate the go-around mode when manipulating or holding the speedbrake lever as a result of unintended contact between the hand or wrist and the go around switch.

  • A-20-038Open - Acceptable ResponseCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Convene a panel of aircraft performance, human factors, and aircraft operations experts to study the benefits and risks of adapting military automatic ground collision avoidance system technology for use in civil transport-category airplanes and make public a report on the committee’s findings.

Sequence of events

16 timed eventsfrom the FDR factual report · claude-fable-5-1 (manual, phase 1)
  1. 10:33takeoff/climbp.5
    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
  2. 12:25descentp.5
    Initial descent out of 34,000 ft began; autoflight systems in LNAV/VNAV modes
  3. 12:36:27descentp.5
    Autopilot lateral mode changed from LNAV to Heading Select; immediately before reaching 10,000 ft the captain's radio mic was keyed
  4. 12:36:35descentp.5
    Aircraft reached 10,000 ft
  5. about 12:37:00descentp.5
    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
  6. 12:38:04approachp.5
    Flaps selected from up to position 1; autoflight go-around modes armed as flaps began to move
  7. 12:38:26approachp.5
    At about 6,500 ft, triaxial acceleration magnitudes increased, consistent with entering light to moderate turbulence
  8. 12:38:31approachp.5
    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
  9. 12:38:37approachp.5
    Speedbrake handle retracted; engines approached commanded go-around power settings
  10. 12:38:40upsetp.5
    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
  11. 12:38:46upsetp.5
    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
  12. 12:38:47upsetp.5
    Split between left and right elevators noted, 2 to 7 degrees, until 12:38:57
  13. 12:38:55upsetp.6
    Overspeed and Master Warning alerts recorded with airspeed increasing beyond 350 knots
  14. 12:38:57upsetp.6
    Altitude crossed through 3,000 ft; autothrottle switched out of go-around mode and engine TRA began to decrease
  15. 12:38:58upsetp.6
    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
  16. 12:39:03impactp.6
    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

NTSB analysis

from the final report

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.