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NTSB Report
February 23, 2019 · Boeing 767 375 · N1217A
Trinity Bay, TX
Overview
Report Status
Final with probable cause
Event Type
Accident
Date
February 23, 2019
Injury Outcomes
3 injuries (3 fatalities)
Location
Trinity Bay, TX
Aircraft
Boeing 767 375 (1992)
Tail Number
N1217A
Operator
Atlas Air
Injuries
Fatal
Aircraft Damage
Destroyed
NTSB Number
DCA19MA086
The Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/aviation.aspx. The Aircraft Accident Report number is NTSB/AAR-20/02. On February 23, 2019, at 1239 central standard time, Atlas Air Inc. flight 3591, a Boeing 767-375BCF, N1217A, was destroyed after it rapidly descended from an altitude of about 6,000 ft mean sea level and crashed into a shallow, muddy marsh area of Trinity Bay, Texas, about 41 miles east-southeast of George Bush Intercontinental/Houston Airport (IAH), Houston, Texas. The captain, first officer, and a nonrevenue pilot riding in the jumpseat died. Atlas operated the airplane as a Title 14 Code of Federal Regulations Part 121 domestic cargo flight for Amazon.com Services LLC, and an instrument flight rules flight plan was filed. The flight departed from Miami International Airport, Miami, Florida, about 1033 (1133 eastern standard time) and was destined for IAH.
NTSB Probable Cause
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.
Full Narrative
The Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/aviation.aspx. The Aircraft Accident Report number is NTSB/AAR-20/02. On February 23, 2019, at 1239 central standard time, Atlas Air Inc. flight 3591, a Boeing 767-375BCF, N1217A, was destroyed after it rapidly descended from an altitude of about 6,000 ft mean sea level and crashed into a shallow, muddy marsh area of Trinity Bay, Texas, about 41 miles east-southeast of George Bush Intercontinental/Houston Airport (IAH), Houston, Texas. The captain, first officer, and a nonrevenue pilot riding in the jumpseat died. Atlas operated the airplane as a Title 14 Code of Federal Regulations Part 121 domestic cargo flight for Amazon.com Services LLC, and an instrument flight rules flight plan was filed. The flight departed from Miami International Airport, Miami, Florida, about 1033 (1133 eastern standard time) and was destined for IAH.
Flight
Event TypeAccident
Event Time12:39 CST
Nearest AirportGeorge Bush Intercontinental (41nm ESE)
Flight Plan FiledIFR
Flight Plan ActivatedYes
Aircraft FireNo
Aircraft ExplosionNo
Aircraft
AircraftBoeing 767 375
Tail NumberN1217A
Aircraft CategoryAir
DamageDestroyed
OperatorAtlas Air
Operating RulePart 121
Engines2
Engine TypeTurbofan
Engine DetailsGeneral Electric · CF6-80C2B6F · Turbofan · 24995 | General Electric · CF6-80C2B6F · Turbofan · 24995
Seats351
People & Injuries
Injury Summary3 injuries (3 fatalities)
Fatal3
Serious0
Minor0
Uninjured0
Total3
Crew 1First Class · Fatal
Crew 2Age 60 · First Class · Fatal
Crew 3Age 44 · First Class · Fatal
Conditions
ConditionsIMC
LightDaylight
WindCalm
CeilingNone
Temperature / Dew Point0 C / 0 C
Altimeter0
Observation Time12:35
Weather SourceWFAC