Loss of control Accident Boeing 767-375ER (BCF) (WL) N1217A, Saturday 23 February 2019
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Date:Saturday 23 February 2019
Type:Silhouette image of generic B763 model; specific model in this crash may look slightly different    
Boeing 767-375ER (BCF) (WL)
Owner/operator:Amazon Air, opb Atlas Air
Registration: N1217A
MSN: 25865/430
Year of manufacture:1992
Total airframe hrs:91063 hours
Cycles:23316 flights
Engine model:General Electric CF6-80C2B6F
Fatalities:Fatalities: 3 / Occupants: 3
Other fatalities:0
Aircraft damage: Destroyed, written off
Location:Trinity Bay, near Anahuac, TX -   United States of America
Phase: En route
Departure airport:Miami International Airport, FL (MIA/KMIA)
Destination airport:Houston-George Bush Intercontinental Airport, TX (IAH/KIAH)
Investigating agency: NTSB
Confidence Rating: Accident investigation report completed and information captured
Atlas Air flight 5Y3591, a Boeing 767-300 operated for Amazon Air, was destroyed in a crash at Trinity Bay, near Anahuac, Texas, USA. All three on board were killed.
The aircraft departed Miami International Airport, Florida at 11:33 hours local time (16:33 UTC) on a cargo flight to Houston-George Bush Intercontinental Airport, Texas, USA. The cruising altitude of FL400 was reached after 20 minutes. Descent towards Houston was commenced at 12:07 hours local time (18:07 UTC).
About 12:30 the pilots contacted the Houston terminal radar approach control (TRACON) arrival controller and reported descending for runway 26L; the airplane was at 17,800 ft with a ground speed 320 knots.
As the flight descended toward the airport, the flight crew extended the speedbrakes, lowered the slats, and began setting up the flight management computer for the approach. The FO was the pilot flying, the captain was the pilot monitoring, and the autopilot and autothrottle were engaged and remained engaged for the remainder of the flight.
At 12:34, the airplane was descending through 13,800 ft, and the controller advised of an area of light to heavy precipitation along the flight route and that they could expect vectors around the weather. About 12:35, the flight was transferred to the Houston TRACON final controller, and the pilot reported they had received the Houston Automatic Terminal Information System weather broadcast. The controller told the pilots to expect vectors to runway 26L and asked if they wanted to go to the west or north of the weather.
Radar data indicated the airplane continued the descent through 12,000 ft with a ground speed of 290 knots, consistent with the arrival procedure. The pilots responded that they wanted to go to the west of the area of precipitation. The controller advised that to do so, they would need to descend to 3,000 ft expeditiously.
About 12:37, the controller instructed the pilots to turn to a heading of 270°. Radar data indicated the airplane turned, and the automatic dependent surveillance-broadcast (ADS-B) data indicated a selected heading of 270°. The airplane was descending through 8,500 ft at this time.
About 12:38, the controller informed the pilots that they would be past the area of weather in about 18 miles, that they could expect a turn to the north for a base leg to the approach to runway 26L, and that weather was clear west of the precipitation area. The pilots responded, "sounds good" and "ok."
At this time, radar and ADS-B returns indicated the airplane levelled briefly at 6,200 ft and then began a slight climb to 6,300 ft.
Also, about this time, the FDR data indicated that some small vertical accelerations consistent with the airplane entering turbulence. At 12:38:31, the airplane’s go-around mode was activated.
Shortly after, when the airplane’s indicated airspeed was steady about 230 knots, the engines increased to maximum thrust, and the airplane pitch increased to about 4° nose up. The airplane then pitched nose down over the next 18 seconds to about 49° in response to nose-down elevator deflection. The stall warning (stick shaker) did not activate.
FDR, radar, and ADS-B data indicated that the airplane entered a rapid descent on a heading of 270°, reaching an airspeed of about 430 knots. A security camera video captured the airplane in a steep, generally wings-level attitude until impact with the swamp. FDR data indicated that the airplane gradually pitched up to about 20 degrees nose down during the descent.

The NTSB found that 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.
He had a long history of training performance difficulties and his tendency to respond impulsively and inappropriately when faced with an unexpected event during training scenarios at multiple employers suggest an inability to remain calm during stressful situations; a tendency that may have exacerbated his aptitude-related performance difficulties.

Probable Cause: The NTSB determines that the probable cause of this accident was the inappropriate response by the first officer as the pilot flying to an inadvertent activation of the go-around mode, which led to his spatial disorientation and nose-down control inputs that placed the airplane in a steep descent from which the crew did not recover. Contributing to the accident was the captain’s failure to adequately monitor the airplane’s flightpath and assume positive control of the airplane to effectively intervene. 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. Also contributing to the accident was the Federal Aviation Administration’s failure to implement the Pilot Records Database in a sufficiently robust and timely manner.

Accident investigation:
Investigating agency: NTSB
Report number: NTSB/AAR-20/02
Status: Investigation completed
Duration: 1 year and 5 months
Download report: Final report


Atlas Air statement
FAA statement



photo (c) NTSB; Trinity Bay, near Anahuac, TX; February 2019; (publicdomain)

photo (c) NTSB; Trinity Bay, near Anahuac, TX; February 2019; (publicdomain)

photo (c) NTSB; Trinity Bay, near Anahuac, TX; February 2019; (publicdomain)

photo (c) NTSB; Trinity Bay, near Anahuac, TX; 23 February 2019

photo (c) Flightaware; Trinity Bay, near Anahuac, TX; 23 February 2019

photo (c) NTSB; Trinity Bay, near Anahuac, TX; 23 February 2019

photo (c) NTSB; Trinity Bay, near Anahuac, TX; 23 February 2019

photo (c) NTSB; Trinity Bay, near Anahuac, TX; 23 February 2019; (publicdomain)

photo (c) NTSB; Trinity Bay, near Anahuac, TX; 23 February 2019; (publicdomain)

photo (c) NTSB; 02 March 2019; (publicdomain)

photo (c) NTSB; March 2019; (publicdomain)

photo (c) Jaime Escobar; Miami International Airport, FL (MIA/KMIA); 26 October 2017

photo (c) Reiner Geerdts; Miami International Airport, FL (MIA/KMIA); 19 January 2019

Revision history:


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