Investigators blame pilot error for 2019 Atlas Air crash

A white Amazon Air plane with light-blue lettering on runway.

Quick Take:

  • Inadvertent activation of landing abort mode and the co-pilot’s inappropriate response to being disoriented sent the plane straight into the ground, the National Transportation Board said..
  • The captain’s delayed awareness of the situation led to an ineffective response.
  • Cockpit imaging recording devices would help in crash investigations.
  • FAA should set up a database for airlines to share employment histories and performance records for pilots.

The co-pilot of an Atlas Air cargo plane with a poor performance history inadvertently bumped a flight control switch during initial descent, became disoriented and pushed the aircraft into a nose-dive that killed him and two others on board when it crashed into a marshy swamp in Trinity Bay, Texas, last year, according to preliminary findings by federal investigators.

Ground collision avoidance technology and a system for employers to share data on pilot competency could help prevent future accidents, National Transportation Safety Board staff members said during a hearing Tuesday. 

“The FAA has been dragging their feet through quicksand and not making sufficient progress” on a pilot records database, NTSB Chairman Robert Sumwalt said. Congress ordered the creation of such a database in 2010.

Atlas Air (NASDAQ: AAWW) was operating the Boeing 767-300 freighter under contract with online retailer (NASDAQ: AMZN), which uses several providers for its air network. Flight 3591 originated from Miami International Airport with Amazon packages and mail for the U.S. Postal Service and was on initial descent to George H. W. Bush Intercontinental Airport in Houston.

As the plane descended in autopilot and auto-throttle, turbulence likely caused the first officer’s left wrist to slip from the speed brake lever and contact an abort switch that automatically caused the plane to circle around.

The NTSB said video imaging in the cockpit would have helped confirm the activation of the “go-around” mode and reiterated recommendations for the installation of cockpit image recorders. Although accidental activation of the go-around mode is a rare or usually benign event, investigators recommended that pilots of Boeing 767 series planes be informed about the circumstances of the accident to increase awareness about the proximity of the equipment.

The first pilot mistook the slight upward pitch when descent was arrested for a stall, which investigators attributed to a false sensation in the inner ear of the plane’s nose being high. Under normal circumstances, the appearance of outside visual cues allows people to ignore this sensation – what scientists call the Somatogravic Illusion. Cockpits, however, have limited views and since the first officer was not properly monitoring his instruments he suffered spacial disorientation, the investigation found.

The first officer aggressively pushed the controls into a nose-down position, but failed to disconnect the autopilot and manually restore the plane to its original flight profile, contrary to training and Atlas Air standard operating procedures.

“The first officer’s apparent struggles with impulsive action during training scenarios at multiple employers suggest that he had an inability to remain calm during stressful situations,” the investigators said in an oral briefing to the board.

The pilot was focused on setting up the approach and communicating with air traffic control, which delayed his recognition and response to the first officer placing the plane in a nosedive. The investigation failed him for not verbally assuming control and also making manual inputs to the autopilot system.

Deception and failure under stress

The NTSB team said the first officer had a history of training deficiencies and failed check rides. Records show that he repeatedly provided incomplete and inaccurate information about his past employment on resumes and applications he provided to multiple operators. He never disclosed to Atlas Air, for example, that he worked for Commute Air and Air Wisconsin, attributing gaps in his work history to college furloughs and other non-airline work.

“These were deliberate attempts to conceal his history of performance deficiencies and deprive Atlas Air and other former employers of the information necessary to fully evaluate his aptitude and competency as a pilot,” investigators said. 

The Pilot Records Improvement Act requires carriers to conduct a five-year background check and evaluation of prospective pilots, including Federal Aviation Administration certification records and national driver records.

“Because of the deceptions on the first officer’s resume and application Atlas air had an incomplete picture of his history of performance deficiency and was unable to fully evaluate his aptitude and competency as a pilot,” NTSB investigators said. “The first officer’s training demonstrated that when given enough practice he was able to perform highly proceduralized actions, but he became overwhelmed when confronted with novel, complex or unexpected situations. His long history of significant performance difficulties is indicative of low aviation aptitude.” 

To prevent pilots from deceiving employers about their work history, the NTSB recommended the FAA establish, in collaboration with industry, a clearinghouse of pilot selection data to help operators mitigate the risk of hiring pilots with unsuitable characteristics and establish appropriate cutoff scores. 

“The loss of Flight 3591 . . . has had a profound impact on all of us at Atlas Air Worldwide. We remain heartbroken by the accident that claimed the lives of our three friends and colleagues and continue to provide their families with care and support,” CEO John Dietrich said in a statement.

“We have been working closely with the NTSB to learn what took place and why it happened. The NTSB’s report provides valuable findings that will help our company and the aviation community as a whole as we continue to improve safety across our industry.  Of critical importance is the need for an improved federal pilot records database to provide airlines with full visibility of pilot history in the hiring process,” he said.

Earlier this year, the FAA published proposed rules to establish a new database to provide potential employers with rapid access to information about pilot performance and employment records. The FAA said Tuesday it plans to publish the final rule in January, Reuters reported. 

Staff also proposed that the FAA convene a panel of aircraft performance, human factors and aircraft operations experts to study the benefits and risks of adapting automatic ground collision avoidance technology for use in the civil sector. The technology has prevented the loss of at least seven military F-16 fighter planes. The U.S. Defense Department has begun researching the adaptation of ground avoidance technology for the Lockheed C-130 military cargo plane, which is estimated could save $385 million and 34 lives. Further adaptation of those systems to commercial aircraft could dramatically reduce spatial disorientation accidents, the investigators said. 

Click here for more FreightWaves/American Shipper stories by Eric Kulisch.


Analysis: Amazon Air, ATSG grow together

Atlas Air gives pilots pay increase on heels of Q1 growth

Federal court sides with Atlas Air in dispute with pilots