NTSB Cites Pilot Performance In Atlas Air Crash


The National Transportation Safety Board (NTSB) has determined that the Feb. 23, 2019, crash of Atlas Air Flight 3591 was most likely caused by the first officer’s failure to respond appropriately to an inadvertent activation of the Boeing 767 cargo jet’s go-around mode on approach to George Bush Intercontinental/Houston Airport (IAH). According to the board’s report (PDF), the resultant spatial disorientation led the first officer to put the aircraft into a “steep descent from which the crew did not recover.” The investigation also concluded that the first officer had a history of training performance difficulties along with a “tendency to respond impulsively and inappropriately when faced with an unexpected event during training scenarios.”

“While the first officer took deliberate actions to conceal his history of performance deficiencies, Atlas’ reliance on designated agents to review pilot background records and to flag significant concerns was inappropriate and resulted in the company’s failure to evaluate the first officer’s unsuccessful attempt to upgrade to captain at his previous employer,” the NTSB stated. “Additionally, the NTSB found that had the FAA met the deadline and complied with the requirements for implementing the pilot records database as stated in Section 203 of the Airline Safety and Federal Aviation Administration Extension Act of 2010, the pilot records database would have provided hiring employers relevant information about the first officer’s employment history and long history of training performance deficiencies.”

As previously reported by AVweb, the aircraft jet went down about 40 miles from IAH in Trinity Bay, Texas, killing the captain, first officer and a jumpseat pilot. The board also cited the captain’s “failure to adequately monitor the airplane’s flightpath and to assume positive control of the airplane to effectively intervene” to as a contributing factor in the accident. As a result of the investigation, the NTSB has issued six new safety recommendations aimed at addressing “flight crew performance, industry pilot hiring process deficiencies and adaptations of automatic ground collision avoidance system technology.”

Kate O'Connor
Kate O’Connor works as AVweb's Editor-in-Chief. She is a private pilot, certificated aircraft dispatcher, and graduate of Embry-Riddle Aeronautical University.

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  1. So, all well and good and a proper citation of the cause. BUT, WHERE THE HECK WAS THE CAPTAIN DURING ALL OF THIS? ASLEEP IN THE HEAD?
    Bumping a Boeing into G-A mode is fairly easy to do when reaching around the throttles to move the flap handle. Not a hazard easy just not difficult to accomplish. One has to think that the Captain would have noticed what he did and simply said “Oops, sorry about that” while reaching up and hitting the throttle disconnect switch, retarding the throttles and then resetting auto-throttles if they wanted. Instead, he appears to have sat there like a bump on a log until the bay appeared in the windscreen and smote the aircraft mightily. Sounds to me like that was a really bad crew pairing all around.
    Atlas was a really good place to work for the 16 years I flew there. That said, after they hired up the available supply of available military transport guys and a few fighter jocks, they started having to hire out of the civil market. The vast majority of those folks were pretty darn good and wanted to learn. A handful were scary and Atlas was afraid to through them out the door for fear of law suits. There were a couple that some Captains refused to let touch the yoke. I could name one that I assume is still there but will never be a Captain and never trusted, especially hand flying. The Classic was more of a pilot’s airplane than the -400 or -8 are but it was a superb aircraft to fly. The TV community (-400 / -8) wasn’t as friendly a group to be around as us Classic drivers were but certainly sharp enough.

    • David, thanks for your comments. This gives the rest of us some background and context that does not appear in NTSB findings and reports.

    • David I had the same response you do about the Captain. We agree there. Thank you for your analysis.

      Because you sound trustworthy enough to believe, I’ll believe what you said about Atlas’ experience with civilian pilots vs military pilots. From my experience having encountered mostly strong but a few weak ones from each background, that is not the case. Something about “the vast majority of those folks were pretty darn good and wanted to learn” sounds slightly high minded and doesn’t sit all that comfortably with me. I’ll end this reply by saying that there were only two times I ever had to take a corporate jet over from the person in the other seat. In both cases they were ex-military, one being a retired B-1 commander.

    • David, the crash site was 40 miles from the destination. I think it was unlikely they were using flaps that far out. I suspect another cause for activation of the G/A mode such as the F/O reaching for the speed brake handle.

    • David,
      I cannot let your disrespectful comments go unanswered. I have been an airline pilot for over 30 years. I have been an Instructor/Evaluator for a global passenger airline for 25 years. In that time I have trained thousands of airline pilots. This accident happened in a matter of seconds. In your comment you don’t even have the common decency to get the facts straight. Your comments are so unprofessional and ignorant I would guess you are not even a pilot. Just some no nothing blow hard Monday morning quarter backing.
      Three souls were lost on that flight primarily due to a system that allowed a person to be in the control seat that was not qualified to be there. The Captain had seconds to react when he was probably startled by the actions of the other pilot while “hanging” in the straps under less than 1g from the rapid pitch change. Maybe you should watch the four plus hour NTSB hearing on Youtube before any further comments. Better yet, stick to commenting on your local HOA issues and how you would do things differently!

    • According to the NTSB report, as passed on by FlightRadar24’s article, the captain was busy talking to ATC and setting up the approach. It should not be necessary for the pilot monitoring to watch the pilot flying from second to second.

    • Haha David….let me rehash some of Atlas’s Greatest Hits for you…the LCF that wrong airport landed at Jabara? Ultra high time, Ex-military CA. The -400 nearly in the drink Asiana-style at ICN on a CATII approach? Military CA with an FO that had tons of ‘classic, heavy’ time. Low fuel at ANC? Military CA. Hard landing at VCP with severe airframe damage? Military. Pod strike at HKG? Nearly crashed -8 at NRT on takeoff thanks to screwing up CDU inputs? Military…Etc…

      STFU about military being the only people that can fly jets. It’s a myth left over from post -WWII days when the only people that had 4 engine time were ex bomber pilots and thus made up the core of the postwar airline workforce.

      It doesn’t matter a fart in a windstorm what you used to fly- only how you perform NOW. Sure, the FO crashed the 767 and murdered his fellow crew but it could just as easily have been an ex blue-suiter…

      Enjoy your retirement


  2. Atlas seems much too timid about termination for lack of proficiency. The NTSB should be going there rather than lobbying for flight deck video that is not going to be accepted by the airline pilot community.

    • Atlas was hurting to find and keep pilots in the days of pilot shortage. The pay and schedule were not great there esp for a new hire. They were just trying to fill the seats even if it meant keeping people who should not be there. Sad I see the same in other companies.

      • Former Atlas pilot. We had 20% of our class wash out of training. They needed pilots, that’s true. The military/civilian comment, pure trash. There’s more to this than meets the eye. People at Atlas know, not going to mention it here. As much as the E-team is incompetent and constantly blames the pilots (the pilots are great), Atlas was put in a tough spot on this one. The training department had issues, like any other company does, but the head of training was hung out to dry…the pilots of Atlas? Some of the best I’ve ever worked with, under some of the most diverse conditions I’ll ever experience.