NTSB Cites Disturbing Cause Of Fatal Atlas Air Crash

The Safety Board’s report describes a number of causal and contributing factors, leading it to recommend new rules that could have wide-reaching effects on pilots.

An investigator holds the flight data recorder of the Boeing 767-300 that crashed in February of 2019 while on approach to Houston’s George Bush International Airport. Photo courtesy of NTSB.
An investigator holds the flight data recorder of the Boeing 767-300 that crashed in February of 2019 while on approach to Houston’s George Bush International Airport. Photo courtesy of NTSB.
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In some ways, accidents that can’t be avoided are easier to accept than ones that should’ve been avoided but weren’t. The crash of an Atlas Air Boeing 767 operating as Flight 3591 and carrying cargo for Amazon and the United States Postal Service on February 23, 2019, falls into that latter category, according to NTSB investigators. It was an accident that was preventable.

The Board in a public meeting held Tuesday evening ruled the crash was probably caused by the actions of the first officer, who was the pilot flying at the time of the crash. That first officer, the NTSB said, accidentally activated the aircraft’s takeoff/go-around mode, which pilots say isn’t in itself a disaster, but then proceeded to sharply lower the nose into a  very steep descent, from which the crew was unable to recover.

Three people—the captain, the first officer, and a jump-seat non-rev pilot—were killed in the crash.

The board also cited the captain for failing to “adequately monitor the airplane’s flightpath and to assume positive control to effectively intervene” contributed to the crash.

In its report, the Safety Board “concluded the first officer likely experienced a pitch-up somatogravic illusion – a specific kind of spatial disorientation in which forward acceleration is misinterpreted as the airplane pitching up…” caused by the increase in power and subsequent acceleration when the TOGA button was inadvertently activated.  This illusion prompted the first officer, the NTSB release said, “to push forward on the elevator control column” to combat what he thought was a sharp climb. Investigators wrote that the first officer “believed the airplane was stalling and continued to push the control column forward, exacerbating the airplane’s dive.”

In a troubling finding, the Board also found fault with the first officer who, they claim, “deliberately concealed his history of performance deficiencies, which limited Atlas Air’s ability to fully evaluate his aptitude and competency as a pilot,” NTSB Chairman Robert Sumwalt said. “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.”

The NTSB doesn’t have the power to implement such regulations. It can only recommend that the FAA do so, which it in most cases declines to follow through on, for a number of reasons, many of the related to practicality and others, to economics.

The NTSB’s new safety recommendations included ones that would “address flight crew performance” and “industry pilot hiring process deficiencies,” the details of which would be contentious.

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While the FAA is under no obligation to implement such proposals, in this case the agency seems predisposed to crack down on pilot record keeping, as it has signaled in recent proposals. If the FAA does indeed require that pilots disclose such previous negative actions that previously were not required to be disclosed or for which there were no record keeping mechanisms in place, it could mean new levels of jeopardy for pilots and evaluators on many fronts.

We’ll keep you apprised of developments on the NTSB’s recommendations.

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