Narrative:
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 airplanes go-around mode was activated.
Shortly after, when the airplanes 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 officers 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 captains failure to adequately monitor the airplanes flightpath and assume positive control of the airplane to effectively intervene. Also contributing were systemic deficiencies in the aviation industrys selection and performance measurement practices, which failed to address the first officers aptitude-related deficiencies and maladaptive stress response. Also contributing to the accident was the Federal Aviation Administrations failure to implement the Pilot Records Database in a sufficiently robust and timely manner.
» Atlas Air statement
» FAA statement
» NTSB
accident date: 23-02-2019
type: Boeing 767-375ER (BCF) (WL)
registration: N1217A
accident date: 23-02-2019
type: Boeing 767-375ER (BCF) (WL)
registration: N1217A
accident date: 23-02-2019
type: Boeing 767-375ER (BCF) (WL)
registration: N1217A
accident date: 23-02-2019
type: Boeing 767-375ER (BCF) (WL)
registration: N1217A
N1217A
N1217A
accident date: 23-02-2019
type: Boeing 767-375ER (BDSF)
registration: N1217A
accident date: 23-02-2019
type: Boeing 767-375ER (BDSF)
registration: N1217A
| Status: | Accident investigation report completed and information captured |
| Date: | Saturday 23 February 2019 |
| Time: | 12:39 |
| Type: |  Boeing 767-375ER (BCF) (WL) |
| Operated by: | Atlas Air |
| On behalf of: | Amazon Air |
| Registration: | N1217A |
| MSN: | 25865/430 |
| First flight: | 1992-04-21 (26 years 10 months) |
| Total airframe hrs: | 91063 |
| Cycles: | 23316 |
| Engines: | 2 General Electric CF6-80C2B6F |
| Crew: | Fatalities: 2 / Occupants: 2 |
| Passengers: | Fatalities: 1 / Occupants: 1 |
| Total: | Fatalities: 3 / Occupants: 3 |
| Aircraft damage: | Destroyed |
| Aircraft fate: | Written off (damaged beyond repair) |
| Location: | Trinity Bay, near Anahuac, TX ( United States of America)
|
| Phase: | En route (ENR) |
| Nature: | Cargo |
| Departure airport: | Miami International Airport, FL (MIA/KMIA), United States of America |
| Houston-George Bush Intercontinental Airport, TX (IAH/KIAH), United States of America | |
| Flightnumber: | 5Y3591 |
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 airplanes go-around mode was activated.
Shortly after, when the airplanes 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 officers 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:
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 captains failure to adequately monitor the airplanes flightpath and assume positive control of the airplane to effectively intervene. Also contributing were systemic deficiencies in the aviation industrys selection and performance measurement practices, which failed to address the first officers aptitude-related deficiencies and maladaptive stress response. Also contributing to the accident was the Federal Aviation Administrations failure to implement the Pilot Records Database in a sufficiently robust and timely manner.
Accident investigation:
 |
|
Classification:
Loss of control
Sources:
» Flightradar24» Atlas Air statement
» FAA statement
» NTSB
Follow-up / safety actions
NTSB issued 6 Safety Recommendations
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Photos
accident date: 23-02-2019
type: Boeing 767-375ER (BCF) (WL)
registration: N1217A
accident date: 23-02-2019
type: Boeing 767-375ER (BCF) (WL)
registration: N1217A
accident date: 23-02-2019
type: Boeing 767-375ER (BCF) (WL)
registration: N1217A
accident date: 23-02-2019
type: Boeing 767-375ER (BCF) (WL)
registration: N1217A
N1217A
N1217A
accident date: 23-02-2019
type: Boeing 767-375ER (BDSF)
registration: N1217A
accident date: 23-02-2019
type: Boeing 767-375ER (BDSF)
registration: N1217A
Video, social media
Aircraft history
| date | registration | operator | remarks |
|---|---|---|---|
| 21 April 1992 | N6063S | Boeing | first flight |
| 1992 | C-GCAW | Canadian Airlines International | not delivered |
| 16 July 1992 | EI-CFR | GPA | registered |
| 4 Nov. 1992 | B-2561 | China Southern Airlines | |
| Jan. 1997 | CC-CRG | LAN Chile | |
| 14 June 2004 | CC-CRG | LAN Airlines | airline renamed |
| 29 Dec. 2008 | LV-BTE | LAN Argentina | |
| April 2010 | LV-BTE | LAN Argentina | winglets fitted |
| 18 Oct. 2010 | CC-CRG | LAN Airlines | |
| 22 Oct. 2014 | N258CT | CIT Leasing | |
| 27 Jan. 2016 | N258CT | Atlas Air | |
| 5 April 2016 | N631GT | Atlas Air | |
| 8 Dec 2016 | N1217A | Atlas Air | |
| April 2017 | N1217A | Atlas Air | BCF (cargo) conversion |
| 30 Apr 2017 | N1217A | Amazon Prime Air | operated by Atlas |
Map
This map shows the airport of departure and the intended destination of the flight. The line is connecting ADS-B datapoints from Flightradar24.
Distance from Miami International Airport, FL to Houston-George Bush Intercontinental Airport, TX as the crow flies is 1540 km (962 miles).
Accident location: Approximate; accuracy within a few kilometers.
Distance from Miami International Airport, FL to Houston-George Bush Intercontinental Airport, TX as the crow flies is 1540 km (962 miles).
Accident location: Approximate; accuracy within a few kilometers.
This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.
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