Atlas Air Flight 3591

Atlas Air Flight 3591 was a scheduled domestic cargo flight between Miami International Airport and George Bush Intercontinental Airport in Houston, operated by Atlas Air on behalf of Amazon Air. On February 23, 2019, the Boeing 767 operating this flight crashed into Trinity Bay during approach into Houston, killing the two crew members and single passenger on board. The accident occurred near Anahuac, Texas, east of Houston, shortly before 12:45 CST (18:45 UTC). This was the first fatal crash of a Boeing 767 freighter, and the first fatal crash involving Amazon Air.

Investigators attributed the accident to pilot error, finding that the first officer – who had years of flight performance issues at four previous airlines – experienced spatial disorientation and inadvertently placed the aircraft in an unrecoverable dive, while the captain failed to adequately monitor the first officer's actions and the flight path of the aircraft. Flight crew training issues at Atlas Air and across the U.S. commercial aviation industry were also implicated.

Accident

Atlas Air 3591 departed Miami at 10:33 CST (11:33 EST), with First Officer Aska as pilot flying and Captain Blakely pilot monitoring. At 12:36, Aska transferred control of the aircraft to Blakely, telling him that the electronic flight instrument (EFI) switch on his side had malfunctioned. This issue was resolved a minute later, with the following being recorded on the cockpit voice recorder (CVR):

Aska: "I press the E-fy button, it fixes everything."

Blakely: "Oh ya ya."

Flight 3591 was on approach towards Houston when it flew through the forward edge of a cold front, which produced an area of instrument meteorological conditions (IMC) with clouds and turbulence, with cloud tops varying from approximately 19500 ft to 27300 ft of altitude and cloud bases varying from 2000 ft to 3000 ft above ground level. The pilot of another nearby airliner reported IMC, and a video taken by a ground witness showed a shelf cloud passing over the area at the time.

Aska then requested radar vectors to the west side of the airport to avoid the inclement weather. The controller accepted but also advised the crew to expedite their descent to 3000 ft and said, "I'm gunna get ya west of this weather and northbound for a base leg." Blakely then transferred control of the aircraft back to Aska:

Aska: "Ok. Two seven zero."

Blakely: "Your controls."

Aska: "My controls."

The flight crew then started to configure the aircraft for landing and set up the flight management system (FMS). At 12:38:02.2 CST, Aska called out "flaps one”, and the slats were extended. 29 seconds later, the aircraft's go-around mode was inadvertently activated. At 12:38:40.3, the following was heard on the CVR:

Cockpit area microphone (CAM): [Sound of master caution aural warning]

Blakely (radio transmission): "Sounds good uh Giant thirty-five ninety-one."

Approach controller: "It is severe clear on the other side of this stuff so you'll have no problem gettin' the airport [unintelligible word] (either)."

Aska: "Oh. Woah! (Where's) my speed my speed? [Spoken in elevated voice]

CAM: [Sound similar to a mechanical click]

Blakely (radio transmission): "Okay."

Aska: "We're stalling! Stall!" [Exclaimed]

Voice unidentified: "[Expletive]"

Aska: "Lord…you have my soul."

The aircraft sharply turned south before going into a rapid descent. Witnesses to the crash described the plane as entering a nosedive; some also recalled hearing "what sounded like lightning" before the Boeing 767 collided with the ground.

At 12:36 CST (18:36 UTC), radar and radio contact was lost. There was no distress call. At 12:39:03.9 CST (18:39:03.9 UTC), the time the CVR recording ended, Flight 3591 crashed into the north end of Trinity Bay at Jack's Pocket. The area of water is within Chambers County, Texas, in proximity to Anahuac.

The Federal Aviation Administration (FAA) issued an alert after radar and radio contact was lost around 30 mi southeast of its destination. Air traffic controllers tried at least twice to contact the flight, with no response. Controllers asked pilots of two nearby flights whether or not they saw a crash site, both of whom said they did not; the crash site was located after ground witnesses called local police to report having seen the aircraft dive into the bay. The United States Coast Guard dispatched a helicopter and several boats to search for survivors, and other agencies responded. The crash site was mostly mud marsh, with water varying in depth from zero to 5 ft deep, thus airboats were needed to access the area. Searchers found human remains and many small fragments of the aircraft and its cargo. The largest recovered piece of the aircraft was 50 ft in length. The local sheriff described the scene as "total devastation" and surmised that the crash had not been survivable.

Flight crew training issues

The NTSB noted that both pilots had difficulties in their training. Blakely experienced difficulties during training for his type rating on the 767. On October 31, 2015, he was declared unfit for a checkride due to unsatisfactory remarks on his training which included the following:

Allowing airspeed to exceed flap limits during stall recovery training

Forgetting to set the missed approach altitude

Difficulties in performing missed approaches

Blakely underwent remedial training the next day on November 1, this time with satisfactory results. The day after, he had his 767 checkride, and received his type rating on the aircraft two days later. Despite Blakely's improvements, Atlas Air placed him in the pilot proficiency watch program (PWP) due to his training issues.

First officer Aska had also experienced training difficulties with Atlas Air, more so than Blakely. According to the NTSB, Aska had been unable to complete pilot training at two other airlines, which he did not disclose on his job applications to Atlas. The NTSB found that Aska had a "long history of training performance deficiencies", with a "tendency to respond impulsively and inappropriately when faced with an unexpected event during training scenarios". Aska's first issues at Atlas emerged in July 2017, the same month he joined the airline, when he was declined an oral exam for his type rating on the 767 as he needed remediation training. Following the training, he passed the oral exam. Aska then went through five fixed-base (non-moving) flight simulator sessions, experiencing difficulties with normal procedures, and underwent more remediation training. In August, following two full-flight simulator training sessions, Aska's simulator partner complained that he was being "held back". Atlas Air ultimately had to restart full-flight simulator training for Aska because no other pilots remained in his training class to partner with him.

Aska's first checkride on the aircraft ended in failure due to poor crew resource management (CRM) and improper aircraft control. His examiner described him as stressed and lacking situational awareness. Aska underwent remedial training on September 25 and the next day, he reattempted his checkride successfully, receiving his type rating on the aircraft.

The NTSB concluded that Aska had been able to conceal his spotty training record because of shortcomings in the FAA pilot records database, and criticized the FAA for failing to upgrade the database earlier. A 2010 amendment to the Pilot Record Improvement Act (PRIA) passed after the 2009 crash of Colgan Air Flight 3407 required the FAA to record training failures in the database; however, this provision had not been fully implemented due to privacy concerns and industry opposition, particularly from business aviation operators who objected to the program's stringent record-keeping requirements. Atlas Air was also criticized for its reliance on agents rather than flight operations specialists to check the training backgrounds of pilots it hired. Atlas Air's director of training said they would not have hired Aska if they had known his full training record.

The NTSB recommended that pilots of the 767 and the similar Boeing 757 be trained to recognize and recover from inadvertent go-around mode actuation, but also concluded that available data suggested that such an actuation was a "rare and typically benign event".