Pilot Debrief

Boeing 767 near Trinity Bay, TX — 2019-02-23

Final reportDCA19MA086
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Date
2019-02-23
Location
Trinity Bay, TX, USA
Airport
KIAH
Aircraft
Boeing 767
Registration
N1217A
Category
Airplane
Highest injury
Fatal
Fatalities
3

Probable cause

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.

Contributing factors

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.

NTSB narrative

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.

NTSB coding

Evidence available

  • CVR
  • ATC audio
  • Video
  • FDR / data
  • ADS-B / radar
  • 78 docket documents
View NTSB final reportView NTSB docket

Docket documentsshowing 50 of 78

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