NTSB Public Docket Reveals Crew Confusion, Training Discrepancies in Atlas Air 3591 Downing

 - January 13, 2020, 12:34 PM

Although the National Transportation Safety Board (NTSB) has not yet issued its probable cause determination in the Feb. 23, 2019 downing of an Atlas Air Boeing 767 freighter near Houston, Texas, information contained in the Board's recently-released public docket on the investigation paints a picture of a confused flight crew working against one another trying to keep their aircraft in the sky.

Flight 3591 from Miami International Airport (MIA) had proceeded normally for most of its journey to George Bush Intercontinental Airport (IAH), with captain Ricky Blakely, first officer Conrad Aska, and jump-seater Sean Archuleta, a recently promoted captain at Mesa Airlines, discussing their respective employers and the flying qualities of the Boeing 767.

Aska, the pilot flying, reported to Blakely as the aircraft approached IAH that his primary flight display appeared to be showing incorrect aircraft orientation on the horizontal situation indicator (HSI), but the crewmembers later determined the instrument was functioning properly.

The situation deteriorated as the Boeing descended through 10,000 feet msl and maneuvered around thunderstorms circling IAH while approaching to land on Runway 26L. The aircraft's flight data recorder (FDR) noted "triaxial acceleration magnitudes increased" at an altitude of approximately 6,500 feet, "consistent with the aircraft entering light to moderate turbulence," according to the NTSB FDR specialist's factual report.

Five seconds later, the aircraft's go-around autothrottle mode activated and "the engines began advancing to go-around thrust setting," according to the report. However, neither pilot seemed aware the mode had been selected or that their aircraft was now configuring for a 2,000 foot-per-minute climb; until about 10 seconds later, when Aska suddenly pitched the aircraft nose down but did not touch the throttles.

"Whoa, my speed, my speed," Aska stated, according to the NTSB’s cockpit voice recorder (CVR) transcript. "We’re stalling. Stall." However, FDR data indicates the aircraft was flying normally at a computed airspeed of approximately 250 knots prior to the nose pitching down in response to the first officer’s control inputs. Citing a physiologist, the NTSB noted Aska may have been disoriented by the increase in speed while operating in instrument meteorological conditions.

According to the FDR, Blakely then pulled back on his yoke as Aska continued pushing forward, resulting in "a split between left and right elevators...ranging between 2 to 7 degrees," according to the NTSB. The aircraft continued to descend, with airspeed increasing beyond 350 knots.

The plane's autothrottles switched out of go-around mode as the aircraft descended through 3,000 feet, by which time the aircraft had descended under the cloud cover and was in visual conditions. The FDR indicates both Aska and Blakely then pulled back on their yokes to the full aft position, where they remained until the aircraft crashed into a shallow bay approximately 40 miles southeast of IAH.

"Aircraft pitch was about 50 degrees nose down," the FDR report stated. "Vertical acceleration went from 0 g to 4.2 g and pitch increased rapidly until its final recorded position of 16 degrees nose down...The final recorded airspeed was 433.5 kts."

Pilots’ Employment and Training Histories Highlighted

Investigators also found that Aska, 44, had a problematic employment and training history prior to his hiring at Atlas in 2017. He joined the freight operation from Mesa Airlines, which he left after failing two flight simulator checkouts for promotion to captain on the Embraer 175 regional jet. One Mesa captain who evaluated him told the NTSB that Aska would "make frantic mistakes [and] start pushing a lot of buttons without thinking about what he was pushing."

Earlier in his flying career, Aska had been briefly employed by regional airlines Air Wisconsin and Commutair but had left after four months and one month, respectively, due to failure to satisfactorily complete training at both carriers. He did not list his time with those airlines when applying at Atlas, the NTSB noted.

Both Aska and Blakely, 60, also underwent remedial instruction at Atlas, with the latter enrolled in the carrier’s proficiency watch program in 2015 after he initially failed his 767 checkride. Blakely was approved to fly the 767 later that year, following successful retraining on proper stall recovery and missed approach procedures.

Aska also failed his initial checkride at Atlas, due to what company pilots told the NTSB was "unsatisfactory performance in crew resource management, threat and error management, non-precision approaches, steep turns, and judgment." He ultimately passed the checkride after more remedial training, with the chief pilot at Atlas telling investigators he'd chalked up the first officer's previous difficulties to nerves and family issues.

That pilot told the NTSB that he'd intended to informally monitor Aska's performance going forward, but the carrier did not place Aska under a dedicated proficiency watch program as mandated by the FAA.