The crash of Atlas Air 3591 shocked the airline industry. It was caused by a first officer with a long history of poor performance that wasn’t known when he was hired. And an experienced captain in the left seat wasn’t enough to save the airplane or the three lives aboard. In this video, AVweb’s Paul Bertorelli offers a detailed dissection of the accident based on the NTSB sunshine hearing.

This report was first published in 2019.


  1. There is a story in the book ‘They called it Pilot Error’ about a co-pilot who managed to get into the right seat of a Falcon and drove it into the ground on an instrument departure (Chapter 18 ‘Fixation Flight’). He turned out to be unable to operate on instruments even though he had the rating and loads of hours. Although different in many ways, the way in which a pilot who lacks the necessary aviation aptitude, or parts of it, gets into the right seat of an airliner appears somewhat similar. That book is from 1994, I guess there’s still work to be done on this front. Fortunately, events like these are very rare, and I hope that they will become even rarer.

  2. Your description & illustration of the somatogravic illusion in the video is wrong. You show the semicircular canal and the crista ampullaris, but these organs actually detect angular velocity. However, the somatogravic illusion is caused by the otolith organ and the macula utriculi. The otolith organ normally detects head position in a terrestrial environment, but in an aviation environment it can easily mis-interpret acceleration/deceleration as pitch up/down. In this accident, the pilot mis-interpreted acceleration as pitch up, and he then pushed the control yoke to cause the dive.

  3. Paul:

    Thanks for the excellent, but disturbing, presentation on this accident. Thank goodness it was mostly boxes and not 240 passengers. What a nightmare.

    It looks like you’ve misidentified the Go Around buttons on the throttle quadrant of the 767. The button this video points too at 5:55 into it is actually the Auto Throttle disconnect buttons on the side of the throttles. The GA switches are lower and behind the throttles. This makes it easier to understand how they may have been inadvertently hit.

    Thanks for all you do at Avweb. I always enjoy your updates and insight.

    John D Bos
    767 Captain and C172 driver.

  4. As a former check airman for a major airline, I have seen several pilots hired with glowing reports from their previous airline, when in fact they were problem employees and difficult to terminate due to various reasons. In one of the cases the pilot was threatening to sue the previous airline (I won’t give the reason because I don’t want to be labeled) – so that employer gave them a great referral to get them off the property. Once at our airline that person kept a daily journal throughout their training of anything resembling untoward, and when it came time to terminate them, the journal came out with a threat to sue. That person was given another year of probation instead of being terminated. Another pilot who’s claim to fame was that they were a C-17 pilot with the local Air National Guard, as well as a commuter first-officer was the worst pilot I have ever had to instruct. When I flew with this person on OE, if I had become incapacitated everyone on board would have died. They were allowed to start training all over again at the simulator phase after failing the OE phase. Turns out they were only allowed to fly the C-17 with an instructor at the guard unit. Unfortunately these pilots are the safety back-up in the flight deck and due to political reasons they are out there flying the unsuspecting public through the skies. Don’t get me wrong. We had awesome tallented pilots from all walks of life, and fortunately the exceptions are rare, but they exist due to politics. And the politics is only getting worse! Glad to be retired!

    • “I have seen several pilots hired with glowing reports from their previous airline, when in fact they were problem employees and difficult to terminate due to various reasons.”

      That sounds like the double-entendre job reference, “you’d be lucky to get this person to work for you!”

      PS – this kind of pass-the-buck behavior is what got the Boy Scouts and the Catholic Church in trouble. And they didn’t kill anyone. Imagine the industry fallout if a “known” bad pilot kills a plane-load of passengers? Wait, we don’t have to imagine – just look what the goverment did after Colgan Air 3407. But imagine if it happened a *second* time?

  5. In my military officer training, I was taught that doing nothing is a decision in itself, and very often it’s the worst one because it self-perpetuates. One tries to gather as much information as possible (instrument scan?) but ultimately some action has to be taken. Deciding how much time to take to make a decision is often the hardest part.
    The first officer did something, using (faulty) intuition and no actual flight information. It was the wrong choice.
    It would seem that the captain “did nothing” in those first twenty seconds after. That also ended up being a bad “choice” (if we can call it that) unfortunately.

  6. As usual, excellent video, excellent critique.

    Judging from some of the comments to the video and your additional blog relating to this crash, this crash shocked those within the airline industry who do not fly, whose jobs are outside of the actual day to day flying of the aircraft. However, for those regularly flying the line, including the check airmen, it appears to me there is a notable amount of substandard pilots that have accumulated time in spite of histories of busted check rides, poor daily line performance, and unpredictability when faced with an unusual, unexpected event. I don’t know how to quantify “notable amount” but it seems a number higher than we arm chair quarterbacks and even the NTSB might have expected.

    Since Covid-19 has completely turned the airline industry upside down, overnight changing the needs for pilots, mechanics, even new airplanes, with the current reluctance to expose or identify these substandard performing individuals will these people stay in the system or be washed out? The airline industry might capitalize on a high number of qualified, excellent performing pilots looking for a small number of available jobs thereby eliminating the need for those barely performing at the bottom rung minimizing risk of ending up in litigation.

    Maybe there are 50 ways to leave your lover…but there seems to be a lot of hoops an airline needs to jump through to get rid of those demonstrating substandard performance. And those hoops are significant enough to allow people to remain in daily airline/cargo flying when their skills are clearly substandard placing an enormous additional burden on those who are performing up to task.

    Makes me wonder how many airliners are being flown essentially single pilot? As long as they don’t crash, under the current “system”, we really don’t know. The daily, excellent performers do. But the question is, how is this information shared, if it can be shared at all?

  7. While the NTSB’s concept of a pilot performance database sounds like the solution to the problem, it is still fraught with potential issues. First off, no one wants to be the bad guy that denies a person of his or her ability to make a living, regardless of whether that involves pilots or any other profession. If a check pilot knows his evaluation will be published in an open access database for the whole world to see, they may be reluctant to be truly honest with their comments, knowing it could likely end a person’s career. And, unless the FAA provides some legal protection for those check pilots providing the evaluations, they could still be subject to litigation from a person who claims they were “out to get him”. The legal system can get very messy.

  8. Training documentation is a multi-blade sword. I was giving an upgrade PC check ride in a 757 sim with a candidate who was completely unprepared. His performance was abysmal. After about 1 hour I called it quits and explained that everyone has bad days, etc. he could try again the next day, or have another check airman administer the ride if he thought there might be friction between us. I explained that this day would be documented as training. He agreed to the following day after a very lengthy debriefing.
    The next day was just as bad. Not only was he totally unprepared, but his attitude was worse. Ended up downing him explaining that there would be no document of failure for the ride. It was just training. I didn’t want his “unblemished” trading records to be affected. Turns out the training department was unaware of his previous failures at another airline.
    Did a first officer PC and he went on his way.

    Three months later I get a certified letter from his attorney with a personal lawsuit at me. Because I hadn’t “failed” him on the PC he therefore must have passed. I made a phone call to him explaining that I was trying to help him. Instead, because of the lawsuit I would have to retroactively fail him and pink slip him. He finally rescinds the lawsuit.
    The performance he displayed was un fathomable. I think it was the worst performance I had seen in many years of training/checking. His attitude just made everything that much worse.
    One might be surprised that the aptitude of some crew members can be so bad, but unfortunately they are still flying.