The U.S. National Transportation Safety Board determined that the crash of Atlas Air cargo Flight 3591 in a Texas bay in February 2019, was due to the disorientation of the copilot.

On February 23, 2019, the Atlas Air Boeing 767-375BCF registered N1217A, operating cargo Flight 3591 for Amazon.com and the U.S. Postal Service, crashed about 40 miles southeast of George Bush Intercontinental Airport (KIAH), Houston, Texas. Of the three people on board ‒ two pilots and one jumpseat pilot ‒ none survived.

The NTSB determined that the poor training and inability to handle pressure of the copilot contributed to the crash of Atlas Air Flight 3591. The first officer was the pilot flying the airplane at the time of the accident, as the captain was handling the approach preparation to Houston and communicating with air traffic control.

In their final report, the investigators concluded that the first officer was likely affected by what they call a “pitch-up somatogravic illusion”, in which a forward acceleration is misinterpreted as the airplane pitching up. The unexpected acceleration was triggered by the go-around mode which was inadvertently activated by one of the flight crew during turbulence. Thus, fearing the plane was stalling, the copilot pushed the elevator control column, sending the freighter into a descent from which it did not recover. The plane fell more than 3,000 feet (914 meters) in 30 seconds before crashing into Trinity Bay, 40 miles (64 kilometers) from its destination airport.

The NTSB points at the first officer’s employment history and training performance deficiencies, that he did not disclose to Atlas, and that the company failed to identify. “The first officer’s 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,” states the report. 

On that issue, the NTSB blames the Federal Aviation Administration for failing to implement the recommended pilot records database (PRD) in due time, which would have “provided hiring employers relevant information” regarding the first officer.

Atlas Air’s president and CEO, John Dietrich, said his company has improved its hiring procedures since the crash and echoed the NTSB’s call for a stronger pilot database. “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,” Dietrich said in a statement.

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The United States National Transportation and Safety Board (NTSB) has found both flight recorders from the crashed Atlas Air 767 freighter.