Atlas Air flight 3591 crashed outside Houston in 2019 after the first officer, due partly to sensory illusion, improperly reacted to inadvertent activation of the aircraft’s go-around mode.

The National Transportation Safety Board (NTSB), in conclusions released 14 July, also cites first officer airmanship deficiencies and shortcomings by the captain as factors playing a role in the crash.

”Also contributing were systemic deficiencies in the aviation industry’s selection and performance measurement practices, which failed to address the first officer’s aptitude-related deficiencies and maladaptive stress response,” says the safety investigatory agency’s conclusions.

The NTSB also disclosed its findings in a webcast hearing on 14 July. The investigation is complete but the final accident report has not been released.


Source: NTSB

NTSB investigators and recovery team members retrieve Atlas Air flight 3591’s flight data recorder from a Texas marsh on 3 March 2019.

The Federal Aviation Administration says it intends to address some of the NTSB’s concerns next year by requiring sharing of pilot records.

The Atlas Air Boeing 767-300 Boeing Converted Freighter (registration N1217A) crashed as it approached Houston’s George Bush Intercontinental airport on 23 February 2019 during a flight from Miami.

Three people died in the crash: the captain, first officer and a pilot travelling as a passenger.

The accident sequence began when the aircraft was about 35nm (65km) outside Houston, descending in light turbulence through 6,300ft with the first officer at the controls.

The turbulence likely caused the first officer’s wrist or watch to inadvertently activate the jet’s go-around switch. At the time, the first officer was likely holding the speed brake lever, which is near the go-around switch, the report says. The board calls such inadvertent go-around activation “rare and typically benign”.

Despite cockpit notifications, the pilots were apparently unaware of the flight mode transition. Seconds later, one of the pilots – likely the first officer – pushed the aircraft’s control column forward, pitching it nose down, the NTSB says.

”The first officer likely experienced a pitch-up somatogravic illusion as the airplane accelerated due to the inadvertent activation of the go-around mode, which prompted him to push forward on the elevator control column,” the report says.

Such an illusion, which can cause pilots to sense that their aircraft is pitching nose up, can occur during limited outside visibility when an aircraft is accelerating.

The first officer “experienced sensations that [the] airplane was stalling. The aircraft was not stalling,” says NTSB investigator Bill English during the hearing.

Due to the control column input, the aircraft entered a dive from which the pilots were unable to recover.

“The airplane crashed into a shallow, muddy, marshy area of Trinity Bay, Texas,” NTSB board chair Robert Sumwalt says during the hearing.

Source: NTSB

Animation of the final few minutes of the Atlas 767's flight

The board says the captain failed to quickly recognise the first officer’s unexpected actions. Also, the captain’s attempts to arrest the dive were ineffective because the captain failed to “command a positive transfer of control” from the first officer.

But the NTSB says the first officer deliberately withheld from Atlas a history of performance issues.

“The first officer’s repeated uses of incomplete and inaccurate information about his employment history on resumes and applications were deliberate attempts to conceal his history of performance deficiencies and deprived Atlas Air and at least one other former employer of the opportunity to fully evaluate his aptitude and competency as a pilot,” the NTSB says.

The report says Atlas’ use of “designated agents” to verify pilot background records kept Atlas from fully evaluating the first officer.

Atlas Air Worldwide Holdings, which owns Atlas Air, says the “NTSB’s report provides valuable findings that will help our company and the aviation community as a whole as we continue to improve safety across our industry”.

“Of critical importance is the need for an improved federal pilot records database to provide airlines with full visibility of pilot history in the hiring process,” Atlas adds.


To prevent future such accidents, the NTSB urges the FAA to emphasise that aircraft operators should use “flight operations” experts, not designated agents, to review pilot records prior to hiring.

The board recommends that the FAA address shortcomings with an existing, but voluntary, “Pilot Records Database”, which is used to share pilot records among airlines.

The database should include all pilot training records related to airline employment processes, the NTSB says.

The NTSB also reiterates a previous recommendation that airlines, prior to hiring new pilots, be required to obtain and review “notices of disapprovals”. Such forms are records of areas where pilot applicants demonstrate unsatisfactory piloting knowledge or skill.

Asked to comment, the FAA says it expects in January 2021 to publish a rule requiring “the industry provide pilot records” to the Pilot Records Database.

“The FAA will complete the final database after the agency publishes the final rule,” it adds.