NTSB Cites First Officer Actions in Atlas Crash

 - July 17, 2020, 11:22 AM
On March 3, 2019, the NTSB retrieved the data recorder of Atlas Air Flight 3591, a Boeing 767-300 cargo jet, that crashed in the muddy marshland of Trinity Bay Feb. 23, 2019. (Photo: NTSB)

The first officer at the controls of an Atlas Air Boeing 767 inadvertently engaged the autopilot’s go-around mode while preparing to arrive at Houston George Bush Intercontinental Airport on Feb. 23, 2019, and in the resulting confusion took actions that ended with the cargo-carrying 767 crashing into Trinity Bay, according to a draft report from the NTSB. The Board detailed in the draft report problems with the first officer’s background, including “deliberate actions to conceal his history of performance deficiencies…”

During a public meeting held online on July 14, the NTSB concluded that after pushing the go-around button at around 6,000 feet, the first officer felt the airplane seemingly pitching up into a stall. The 767 had received cleared to descend to 3,000 feet and there was no reason to engage the go-around mode, nor did anyone make a callout to let the other pilot know that go-around mode activated.

The feeling of pitching upwards was due to a “pitch-up somatogravic illusion,” the Board explained, “a specific kind of spatial disorientation in which forward acceleration is misinterpreted as the airplane pitching up,” a result of the acceleration that the go-around mode is programmed to accomplish. 

Because he believed the airplane was stalling, the first officer pushed forward on the controls to lower the nose, which caused the 767 to accelerate. He took the action despite the lack of indications of a stall such as stick shaker activation, stall warnings, or nose-high pitch or low airspeed indications. 

As the 767 began speeding downward, the NTSB believes the captain was busy with other pilot-monitoring tasks, including setting up the approach and communicating with ATC, and that he wasn’t “monitoring the airplane’s state and verifying that the flight was proceeding as planned. This delayed his recognition of, and his response to, the first officer’s unexpected actions that placed the plane in a dive.” 

For unexplained reasons, the captain did not take over the controls, and the first officer kept forcing the 767 downward, pushing the controls forward against the autopilot’s efforts to climb the airplane as programmed to when the go-around mode is engaged. In seconds, the NTSB reported, the airplane entered “into a steep dive from which the crew did not recover.” 

Only 32 seconds after go-around mode was engaged and with the autopilot still on and power at maximum thrust, the 767 hit the water at more than 430 knots. 

The NTSB determined that the probable cause of the accident was the inappropriate response by the first officer, as the pilot flying, to 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. The captain’s failure to adequately monitor the airplane’s flightpath and assume positive control of the airplane to effectively intervene contributed to the accident, as did 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. The Safety Board also named the FAA’s failure to implement the Pilot Records Database "in a sufficiently robust and timely manner” as a factor.

One of the NTSB recommendations resulting from the accident centered on the requirement for more detailed information, including training records, in the Pilot Records Database. NTSB chairman Robert Sumwalt summarized the finding in a statement from the public hearing: “The first officer in this accident deliberately concealed his history of performance deficiencies, which limited Atlas Air’s ability to fully evaluate his aptitude and competency as a pilot. Therefore, today we are recommending that the pilot records database include all background information necessary for a complete evaluation of a pilot’s competency and proficiency.”