NTSB cites pilot error in 2019 Amazon Air crash

Amazon Air crash

The National Transportation Safety Board (NTSB) has determined that Atlas Air flight 3591, which was operating on behalf of Amazon Air, crashed while on approach to Houston’s George Bush Intercontinental Airport because of pilot error.

At an NTSB board meeting held Tuesday, it was revealed that the first officer’s inappropriate response to an inadvertent activation of the airplane’s go-around mode, caused him to become disoriented and place the airplane in a steep descent from which the crew did not recover.

The Atlas Air Boeing 767 cargo plane crashed on February 23, 2019 into Trinity Bay, Texas about 40 miles from the airport. The aircraft rapidly descended from 6,000 feet and impacted a marshy bay killing the two pilots and a third one who was occupying the jumpseat. The airplane departed Miami and was being flown by the first officer at the time of the accident.

According to the NTSB, the captain failed to adequately monitor the airplane’s flightpath and assume positive control of the airplane, which contributed to the crash. Another contributing factor cited by the NTSB is the aviation industry’s selection and performance measurement practices that failed to address the first officer’s aptitude related deficiencies and maladaptive stress response.

The NTSB 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 – as the airplane accelerated due to the inadvertent activation of the go-around mode, which prompted the first officer to push forward on the elevator control column.

The first officer subsequently believed the airplane was stalling and continued to push the control column forward, exacerbating the airplane’s dive.

Crash investigators did not find any cues consistent with an aerodynamic stall — such as stick shaker activation, stall warning annunciations, nose-high pitch indications or low airspeed indications.

Additionally, the NTSB’s airplane performance study found the airplane’s airspeed and angle of attack were not consistent with having been at or near a nose-high stalled condition. The first officer’s response was contrary to standard procedures and training for responding to a stall.

Graphic depicting of the descent of Atlas Air flight 3591 before final impact on Feb. 23, 2019.
(Graphic depicting of the descent of Atlas Air flight 3591 before final impact on Feb. 23, 2019. NTSB Graphic)

The NTSB concluded that while the captain, as the pilot monitoring, was setting up the approach to Houston and communicating with air traffic control, his attention was diverted from 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.

It was found that the first officer concealed his history of performance deficiencies, and Atlas’ reliance on designated agents to review pilot background records and to flag significant concerns was inappropriate.

Robert Sumwalt, NTSB Chairman said, “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.”

The FAA was also found wanting because it failed to meet the deadline and complied with the requirements for implementing the pilot records database as stated in Section 203 of the Airline Safety and Federal Aviation Administration Extension Act of 2010. The pilot records database would have provided hiring employers with relevant information about the first officer’s employment history and long history of training performance deficiencies.

“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,” added Sumwalt.

Click here for an abstract of the final report, which includes the findings and probable cause.