Rapid Descent and Crash Into Water, Atlas Air Inc. Flight 3591, Boeing 767-375BCF, N1217A, Trinity Bay, Texas, February 23, 2019
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Rapid Descent and Crash into Water Atlas Air Inc. Flight 3591 Boeing 767-375BCF, N1217A Trinity Bay, Texas February 23, 2019 Accident Report NTSB/AAR-20/02 National PB2020-101004 Transportation Safety Board NTSB/AAR-20/02 PB2020-101004 Notation 65227 Adopted July 14, 2020 Aircraft Accident Report Rapid Descent and Crash into Water Atlas Air Inc. Flight 3591 Boeing 767-375BCF, N1217A Trinity Bay, Texas February 23, 2019 National Transportation Safety Board 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 National Transportation Safety Board. 2020. Rapid Descent and Crash into Water, Atlas Air Inc. Flight 3591, Boeing 767-375BCF, N1217A, Trinity Bay, Texas, February 23, 2019. Aircraft Accident Report NTSB AAR-20/02. Washington, DC: NTSB Abstract: This report discusses the February 23, 2019, accident involving Atlas Air Inc. flight 3591, a Boeing 767-375BCF, N1217A, that was destroyed after it rapidly descended from an altitude of about 6,000 ft mean sea level and crashed into a shallow, muddy marsh area of Trinity Bay, Texas, about 41 miles east-southeast of George Bush Intercontinental/Houston Airport, Houston, Texas. The captain, first officer, and a nonrevenue pilot riding in the jumpseat died. Safety issues identified in this report include inadvertent activation of the go-around mode, flight crew performance, Atlas’ evaluation of the first officer, industry pilot hiring process deficiencies, awareness information for Boeing 767 and 757 pilots, adaptations of automatic ground collision avoidance technology, and cockpit image recorders. As a result of this investigation, the National Transportation Safety Board makes six new safety recommendations and reiterates two safety recommendations to the Federal Aviation Administration. The National Transportation Safety Board (NTSB) is an independent federal agency dedicated to promoting aviation, railroad, highway, marine, and pipeline safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974, to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The NTSB makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. The NTSB does not assign fault or blame for an accident or incident; rather, as specified by NTSB regulation, “accident/incident investigations are fact-finding proceedings with no formal issues and no adverse parties … and are not conducted for the purpose of determining the rights or liabilities of any person” (Title 49 Code of Federal Regulations section 831.4). Assignment of fault or legal liability is not relevant to the NTSB’s statutory mission to improve transportation safety by investigating accidents and incidents and issuing safety recommendations. In addition, statutory language prohibits the admission into evidence or use of any part of an NTSB report related to an accident in a civil action for damages resulting from a matter mentioned in the report (Title 49 United States Code section 1154(b)). For more detailed background information on this report, visit the NTSB investigations website and search for NTSB accident ID DCA19MA086. 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Alexandria, VA 22312 (800) 553-6847 or (703) 605-6000 NTIS website NTSB Aircraft Accident Report Contents Figures and Table ............................................................................................................ iii Abbreviations ................................................................................................................... iv Executive Summary ........................................................................................................ vii Probable Cause.................................................................................................................. vii Safety Issues..................................................................................................................... viii Findings............................................................................................................................ viii Recommendations .............................................................................................................. xi New Recommendations .............................................................................................. xi Previously Issued Recommendations Reiterated and Classified in this Report ........ xii Previously Issued Recommendations Reiterated in this Report ............................... xiii 1. Factual Information .......................................................................................................1 1.1 History of Flight .............................................................................................................1 1.2 Personnel Information ....................................................................................................3 1.2.1 Captain .................................................................................................................3 1.2.1.1 Training History at Atlas ............................................................................ 4 1.2.1.2 Certificate History and Previous Employment ........................................... 5 1.2.2 First Officer .........................................................................................................5 1.2.2.1 Training History at Atlas ............................................................................ 5 1.2.2.2 Certificate History and Previous Employment ........................................... 7 1.3 Airplane Information .....................................................................................................8 1.3.1 Electronic Flight Instrument System .................................................................10 1.3.1.1 General ...................................................................................................... 10 1.3.1.2 Electronic Flight Instrument Switch ......................................................... 12 1.3.2 Go-Around Switches .........................................................................................14 1.4 Meteorological Information .........................................................................................14 1.5 Flight Recorders ...........................................................................................................16 1.6 Wreckage and Impact Information ..............................................................................16 1.6.1 General ...............................................................................................................16 1.6.2 Examinations of Structures, Engines, and Systems ...........................................18 1.7 Medical and Pathological Information.........................................................................19 1.8 Tests and Research .......................................................................................................19 1.8.1 Airplane Performance Study ..............................................................................19 1.8.2 Boeing 767 Simulator Scenario Observations ...................................................21 1.8.3 Events Involving Inadvertent Go-Around Mode Activation .............................24 1.8.4 Terrain Awareness and Warning System Simulation ........................................24 1.9 Organizational and Management Information .............................................................25 1.9.1 Flight Crew Procedures .....................................................................................26 1.9.1.1 Respective Roles of Pilot Flying and Pilot Monitoring ............................ 26 1.9.1.2 Automated Flight System Management.................................................... 27 1.9.1.3 Stall Recovery ........................................................................................... 27 1.9.1.4 Pitch Upset Recovery ................................................................................ 28 1.9.2 Pilot Training Program ......................................................................................29 i NTSB Aircraft Accident Report 1.9.2.1 Proficiency Watch Program ...................................................................... 29 1.9.2.2 Remedial Training Decisions for Accident Flight Crew .......................... 30 1.9.3 Pilot Hiring Process ...........................................................................................30 1.9.3.1 General ...................................................................................................... 30 1.9.3.2 PRIA Records Review .............................................................................