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Accident Overview
Atlas Air Inc. (Atlas) flight 3591, a Boeing 767-375BCF, N1217A, was destroyed as it rapidly plummeted from 6,000 ft msl and crashed in Trinity Bay, Texas, about 41 miles east-southeast of George Bush Intercontinental/Houston Airport (IAH), Houston, Texas. The Captain, FO, and jumpseat pilot died. Atlas operated the plane as a Part 121 domestic freight flight for Amazon.com Services LLC and filed an IFR flight plan. The flight left MIA for IAH at 1033 (1133 EST).
General Details Of Accident
In this case, the weather did not seem to have a role. The pilots planned to fly around a small cell before continuing on to their final target airfield. The plane was in perfect working order, had received regular maintenance, was properly balanced, and was carrying just about half of its maximum takeoff weight.
Final Seconds of Flight
During the final few seconds of flight, selected airplane characteristics and crew statements are provided.
Captain Experience Level/Training History
The 60-year-old Captain had 757, 767, and ERJ145 ratings. In 2015, he was hired as a FO, and in 2018, he was promoted to Captain. In 2015, Atlas put the Captain in the pilot proficiency watch program because he did not pass his training as an FO in 2015(National Transportation Safety Board [NTSB], 2019). In 2016, he finished recurrent training for the Boeing 767. This training included three stalls (at takeoff, landing, and clean) and checks of his skills. The Captain took Boeing 767 captain-upgrade ground training in 2018 while he was a first officer. He finished training in upgrade systems on August 15, and on August 23, it was suggested that he become a captain. On August 25, 2018, he passed a check of his skills as a captain.
First Officers Experience Level/Training History
The 44-year-old FO had type ratings for Boeing 757 and 767 and Embraer EMB120, ERJ145, ERJ170, and ERJ190. The FO joined Atlas on July 3, 2017, and obtained his Boeing 767 type rating in 2017. The FO finished Atlas basic indoctrination on July 7 and Boeing 767 ground school on July 22. On July 27, 2017, he was not recommended for his Boeing 767 type-rating oral exam due to his requirement for corrective training. The FO concluded fixed-base training on August 8, 2017. The examiner stated the FO didnt plan ahead and, when he needed to do anything, he often pushed the wrong button. The examiner was concerned that the FO wouldnt mentally recover enough to finish the course. The FO got remedial training on September 25, 2017, and passed the next day.
Aircraft Maintenance
Originally built for passenger use in 1992, it has now been modified for use in carrying freight. In 2017, Atlas got the plane ready for flight and got it a certificate to fly (National Transportation Safety Board, 2019). A Honeywell auxiliary power unit and two General Electric CF6-80C2B6F turbofans. Using a continual analysis and surveillance system and a reliability program that have both been approved by the FAA, the aircraft is kept in a state of constant airworthiness. There are no outstanding issues or discrepancies in the Review files. There were a total of 91,063 flight hours and 23,316 flight cycles. All cargo was loaded within the structural constraints for its designated compartment and within the weight and center-of-gravity limits.
Causal Factors
The NTSB said that the likely cause of this accident was that the first officer, who was flying the plane, did not know what to do when the go-around mode was accidentally turned on. This caused him to lose his sense of space and make control inputs that sent the plane into a steep descent from which the crew could not recover. The accident happened because the Captain did not keep an eye on the planes flight path well enough or take control of the plane to act quickly enough. Systemic flaws in the way the aviation industry chose employees and measured their performance, which did not address the first officers lack of aptitude and bad way of handling stress, also played a role. The Federal Aviation Administrations failure to set up the pilot records database in a strong and timely way also played a role in the crash.
NTSB Findings
The First Officer had a very poor training history despite being technically certified to fly, according to the NTSB. If Atlas Air had known about his past, its likely that they would not have employed him. He was the worst pilot they had ever seen, according to his former teachers. The FO accidentally pressed the Go-Around button due to a lack of FMA awareness. The time between that point and ground contact was 32 seconds. Additionally, it took almost 20 seconds for the Captain to respond verbally on the cockpit voice recorder.
NTSB Recommendations
The PRIA documentation was updated in a number of ways per NTSB recommendations. They suggested that airlines store their records in a more uniform format so that they may be better understood by the hiring committees of other airlines. to include a more thorough and transparent record for each pilot applicant. The NTSB also suggests issuing a safety announcement to all pilots regarding improved unintentional TOGA activation and response procedures. The FAA should look into the possibility of using Automatic Ground Collision Avoidance technology in civil aircraft.
Student Recommendations
As a pilot with experience in the aviation industry, maintaining composure under pressure is one of my most fundamental abilities. It is not always something that can be taught. It needs to be developed by the person. According to the investigations, his training department should not have recommended this pilot for examination or certification. He responded quickly.
References
National Transportation Safety Board. (2019). Rapid descent and crash into water national transportation safety board. Web.
NTSB animation Rapid descent and crash into water Atlas Air inc. flight 3591. (2020). Web.
Ranter, H. (2020). ASN aircraft accident Boeing 767-375ER (BCF) (WL) N1217A trinity bay, near Anahuac, TX. Aviation-Safety.net. Web.
Transportation Research Academy. (2020). Aircraft accident report: Rapid descent and crash into the water, atlas air inc. flight 3591, Boeing 767-375BCF, N1217A, trinity bay, texas, February 23, 2019. Trid.trb.org. Web.
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