Atlas Air 3591 NTSB Public Docket Opened
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Atlas Air 3591 NTSB Public Docket Opened
Docket opened for the February 2019 IAH B767 freighter crash.
NTSB News Release
The link on the Commodore 64 server is a little slow to open right now. I've attached the CVR Report to this post.
NTSB News Release
National Transportation Safety Board Office of Public Affairs
NTSB Opens Public Docket for Investigation of Atlas Air Flight 3591 Cargo Plane Crash
12/19/2019
WASHINGTON (Dec. 19, 2019) — The National Transportation Safety Board opened the public docket Thursday as part of its ongoing investigation of the Feb. 23, 2019, Atlas Air flight 3591 crash into Trinity Bay, Texas.
The accident occurred when a Boeing 767-300 Atlas Air cargo jet entered a rapid descent from 6,200 feet and impacted a marshy bay area about 40 miles from Houston’s George Bush Intercontinental Airport. The two pilots and one non-revenue jumpseat pilot were fatally injured. The airplane was destroyed. The airplane was carrying cargo from Miami to Houston for Amazon.com Inc., and the US Postal Service.
(Graphic depiction of the descent of Atlas Air flight 3591 and the communication between air traffic control and the aircraft pilots on Feb. 23, 2019. NTSB Graphic)Graphic depiction of the descent of Atlas Air flight 3591 and the communication between air traffic control and the aircraft pilots on Feb. 23, 2019. NTSB Graphic)
The docket includes more than 3,000 pages of factual reports that cover various aspects of the investigation, including operations, survival factors, human performance, air traffic control, aircraft performance, and includes the cockpit voice recorder transcript, sound spectrum study, and the flight data recorder information. The docket also includes interview transcripts, photographs, and other investigative materials.
The docket contains only factual information collected by NTSB investigators; it does not provide the final report, analysis, findings, recommendations, or probable cause determinations. No conclusions about how or why the crash occurred should be drawn from the information within the docket. Analysis, findings, recommendations, and probable cause determinations related to the crash will be issued by the NTSB in a final report at a later date.
The public docket for this investigation is available online at: https://go.usa.gov/xp7gH
Additional material may be added to the docket as it becomes available.
The accident occurred when a Boeing 767-300 Atlas Air cargo jet entered a rapid descent from 6,200 feet and impacted a marshy bay area about 40 miles from Houston’s George Bush Intercontinental Airport. The two pilots and one non-revenue jumpseat pilot were fatally injured. The airplane was destroyed. The airplane was carrying cargo from Miami to Houston for Amazon.com Inc., and the US Postal Service.
(Graphic depiction of the descent of Atlas Air flight 3591 and the communication between air traffic control and the aircraft pilots on Feb. 23, 2019. NTSB Graphic)Graphic depiction of the descent of Atlas Air flight 3591 and the communication between air traffic control and the aircraft pilots on Feb. 23, 2019. NTSB Graphic)The docket includes more than 3,000 pages of factual reports that cover various aspects of the investigation, including operations, survival factors, human performance, air traffic control, aircraft performance, and includes the cockpit voice recorder transcript, sound spectrum study, and the flight data recorder information. The docket also includes interview transcripts, photographs, and other investigative materials.
The docket contains only factual information collected by NTSB investigators; it does not provide the final report, analysis, findings, recommendations, or probable cause determinations. No conclusions about how or why the crash occurred should be drawn from the information within the docket. Analysis, findings, recommendations, and probable cause determinations related to the crash will be issued by the NTSB in a final report at a later date.
The public docket for this investigation is available online at: https://go.usa.gov/xp7gH
Additional material may be added to the docket as it becomes available.
The link on the Commodore 64 server is a little slow to open right now. I've attached the CVR Report to this post.
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Oh, and on a quick first skim-read, the authors might need to look up the difference between "silicon" and "silicone".
Last edited by Paul852; 19th Dec 2019 at 17:15.
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Information in the docket indicates that the FO had a history of multiple training failures and busted checkrides at Atlas, Mesa and Trans States and that he flunked out of initial training at Air Wisconsin and CommutAir. Some of these failures showed up in the PRIA (Pilot Records Improvement Act) report ordered for the Atlas job application but were not passed to the Atlas Director of Training before he did the job interview.
As I've observed in earlier threads, poor training performance and awful past employment history seem to be common findings in these freighter mishaps.
As I've observed in earlier threads, poor training performance and awful past employment history seem to be common findings in these freighter mishaps.
In several of these widebody freighter mishaps a crewmember with a very unsatisfactory employment and training history is revealed in the investigation.
In the 1995 FedEx 705 hijack attempt Auburn Calloway was unable to check out as aircraft commander in the Navy and had been fired by American and Flying Tigers before he was hired at FedEx.
RS, the copilot in the 2003 FedEx 647 MEM MD-10 crash had her ticket pulled a couple of times prior to the mishap due to training deficiencies. She also had other employment challenges including DUI's.
CB, captain on the 2013 UPS 1354 crash at BHM had been let go by TWA prior to his 1990 hiring by UPS. He had a history of repeated training failures including open book homestudy exams but was eventually able to upgrade to captain in 2009.
On a perhaps related note, freighters continue to crash at a much higher rate than pax aircraft at U.S. carriers. Is this due to less oversight? Or lower standards and a more challenging operating environment?
Will Atlas 3591 turn out to be yet another widebody freighter loss due to 'human factors'? Is a higher accident rate acceptable for cargo planes since the crashes cause 'no significant loss of life'?
In past years much of the discussion here was focused on the string of mishaps and hull losses at FedEx. As I posted in 2006:
In the 1995 FedEx 705 hijack attempt Auburn Calloway was unable to check out as aircraft commander in the Navy and had been fired by American and Flying Tigers before he was hired at FedEx.
RS, the copilot in the 2003 FedEx 647 MEM MD-10 crash had her ticket pulled a couple of times prior to the mishap due to training deficiencies. She also had other employment challenges including DUI's.
CB, captain on the 2013 UPS 1354 crash at BHM had been let go by TWA prior to his 1990 hiring by UPS. He had a history of repeated training failures including open book homestudy exams but was eventually able to upgrade to captain in 2009.
On a perhaps related note, freighters continue to crash at a much higher rate than pax aircraft at U.S. carriers. Is this due to less oversight? Or lower standards and a more challenging operating environment?
Will Atlas 3591 turn out to be yet another widebody freighter loss due to 'human factors'? Is a higher accident rate acceptable for cargo planes since the crashes cause 'no significant loss of life'?
In past years much of the discussion here was focused on the string of mishaps and hull losses at FedEx. As I posted in 2006:
Quote:
Originally Posted by Airbubba 
(February 2006) >>by now FED EX must have one of the worst hull loss records in the industry!
Sadly, FedEx seems to have a widebody hull loss every two or three years. If they were a pax carrier there would be enormous adverse publicity and probably many casualties as well.
I've got friends over at FedEx who tell me the FAA has been all over their training for years now. Instead of annual AQP sim checks like most U.S. carriers, they are under a closely monitored old style six month program.
The pilot flying in the December 2003 MD-10 hard landing and fire at MEM had a history of busted checkrides before she was hired. In April, 1994 the feds pulled her ATP after an FAA inspector observed her performance. She took more training and got the ATP back and was hired by FedEx in 1996. At FedEx she had more checkride failures, a couple of DUI's and an altitude bust that set up the fateful Mad Dog line check back into MEM. Is it possible that "diversity" was promoted over performance in this case? A possibly similar precedent at FedEx was the overlooked poor employment history of Auburn Calloway who brutally attempted to hijack a FedEx DC-10 in MEM in 1994.
Traditionally, FedEx has had very high employment standards for the freight world, i.e. almost all pilots have college degrees (well, there are some Naval Academy graduates <g>) and many are like the founder, Fred Smith, ex-military aviators [I was later corrected on this point, FS was a Marine officer but not an aviator - Airbubba]. The company is consistently profitable and maintenance is excellent by most accounts.
Still, the mishaps and hull losses continue at what everyone agrees is an unacceptable rate...
(February 2006) >>by now FED EX must have one of the worst hull loss records in the industry!Sadly, FedEx seems to have a widebody hull loss every two or three years. If they were a pax carrier there would be enormous adverse publicity and probably many casualties as well.
I've got friends over at FedEx who tell me the FAA has been all over their training for years now. Instead of annual AQP sim checks like most U.S. carriers, they are under a closely monitored old style six month program.
The pilot flying in the December 2003 MD-10 hard landing and fire at MEM had a history of busted checkrides before she was hired. In April, 1994 the feds pulled her ATP after an FAA inspector observed her performance. She took more training and got the ATP back and was hired by FedEx in 1996. At FedEx she had more checkride failures, a couple of DUI's and an altitude bust that set up the fateful Mad Dog line check back into MEM. Is it possible that "diversity" was promoted over performance in this case? A possibly similar precedent at FedEx was the overlooked poor employment history of Auburn Calloway who brutally attempted to hijack a FedEx DC-10 in MEM in 1994.
Traditionally, FedEx has had very high employment standards for the freight world, i.e. almost all pilots have college degrees (well, there are some Naval Academy graduates <g>) and many are like the founder, Fred Smith, ex-military aviators [I was later corrected on this point, FS was a Marine officer but not an aviator - Airbubba]. The company is consistently profitable and maintenance is excellent by most accounts.
Still, the mishaps and hull losses continue at what everyone agrees is an unacceptable rate...
Will Atlas 3591 turn out to be yet another widebody freighter loss due to 'human factors'? Is a higher accident rate acceptable for cargo planes since the crashes cause 'no significant loss of life'?
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What makes you consider this? To me, the transcript reveals startled pilots, completely caught by surprise and out of the loop until realizing the inevitable outcome.
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Last comments similar to other crashes proven to be intentional?
Eerily similar to Al-Batouti's while taking the plunge.
No doubt that aspect will be fully investigated.
Also non pertinent conversation has probably been redacted in the version released to the public.
fog
Eerily similar to Al-Batouti's while taking the plunge.
No doubt that aspect will be fully investigated.
Also non pertinent conversation has probably been redacted in the version released to the public.
fog
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Last comments similar to other crashes proven to be intentional?
Eerily similar to Al-Batouti's while taking the plunge.
No doubt that aspect will be fully investigated.
Also non pertinent conversation has probably been redacted in the version released to the public.
fog
Eerily similar to Al-Batouti's while taking the plunge.
No doubt that aspect will be fully investigated.
Also non pertinent conversation has probably been redacted in the version released to the public.
fog
The report doesn’t mention anything about redaction. The only omissions are the standard ones made, presumably to edit out expletives.
redacted material is often of conversations that are personal in nature and have no bearing on the operation of the aircraft other than the time it takes to say them. If there are any other reasons for redaction it is typical for the group to provide the reason.
Anything obviously significant would have ;leaked out by now anyway so give up on the conspiracies along these lines
Anything obviously significant would have ;leaked out by now anyway so give up on the conspiracies along these lines
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redacted material is often of conversations that are personal in nature and have no bearing on the operation of the aircraft other than the time it takes to say them. If there are any other reasons for redaction it is typical for the group to provide the reason.
Anything obviously significant would have ;leaked out by now anyway so give up on the conspiracies along these lines
Anything obviously significant would have ;leaked out by now anyway so give up on the conspiracies along these lines
On the whole, American Christians tend to view suicide as one of the worst sins, and never a passport into Heaven.
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From the Airplane Performance Study in the docket:
It now appears that the 'leaked' info from months ago posted on earlier threads ago was from good sources.
Another perfectly good airplane flown into the ground/water due to 'human factors'?
Figure 3 highlights the descent during the last two minutes of the flight with select paraphrased CVR comments overlaid. The descent appears normal until about 1238:31 and approximately 6,300 ft pressure altitude when the go-around mode was activated using one of the Go-around (G/A) buttons on the throttle quadrant: see Figure 4. There was no mention of initiating a goaround by the flight crew on the cockpit voice recorder (CVR), and flight 3591 had been cleared to descend to 3,000 ft. (The normal load factor, an, in Figure 6 shows that the airplane encountered turbulence at approximately 1238:25, six seconds before the recorded flight mode transitioned to G/A. The turbulence was likely associated with the cold front mentioned earlier and included instrument meteorological conditions or IMC.)
The airplane Euler angles recorded on the FDR are shown in Figure 5. The airplane pitch attitude increased from about -1˚ airplane-nose-down (AND) before G/A was annunciated to approximately 4˚ airplane-nose-up (ANU) six seconds later at 1238:37. The airplane then pitched AND to about -49˚ over the next 18 seconds in response to an AND elevator input.
At 1238:48 and 1238:51, the pilot flying (the first officer in the right seat) made comments about the airplane stalling that were recorded on the CVR. However, Figure 6 shows the recorded airplane wing angle-of-attack and airspeed were below -15˚ and above 250 kt, respectively. This is well below the airplane’s wing stall angle-of-attack.
Figure 7 shows an elevator split between the left and right sides of the airplane: the left elevator is associated with the captain in the left seat, and the right elevator is associated with the first officer in the right seat. The elevator deflections are similar until about 1238:46. At that time, the first officer is heard asking a question about airspeed on the CVR, and the elevators begin to split: the captain begins to pull from 2˚ to 8˚ more ANU elevator than the first officer. The split continues until about 1238:56, about one second after the airplane would have broken out of the reported 3,500 ft cloud layer. Both the captain and the first officer subsequently commanded ANU elevator until impact. (The normal load factor recorded by the FDR in Figure 6 is greater than 4g right before impact.)
The airplane Euler angles recorded on the FDR are shown in Figure 5. The airplane pitch attitude increased from about -1˚ airplane-nose-down (AND) before G/A was annunciated to approximately 4˚ airplane-nose-up (ANU) six seconds later at 1238:37. The airplane then pitched AND to about -49˚ over the next 18 seconds in response to an AND elevator input.
At 1238:48 and 1238:51, the pilot flying (the first officer in the right seat) made comments about the airplane stalling that were recorded on the CVR. However, Figure 6 shows the recorded airplane wing angle-of-attack and airspeed were below -15˚ and above 250 kt, respectively. This is well below the airplane’s wing stall angle-of-attack.
Figure 7 shows an elevator split between the left and right sides of the airplane: the left elevator is associated with the captain in the left seat, and the right elevator is associated with the first officer in the right seat. The elevator deflections are similar until about 1238:46. At that time, the first officer is heard asking a question about airspeed on the CVR, and the elevators begin to split: the captain begins to pull from 2˚ to 8˚ more ANU elevator than the first officer. The split continues until about 1238:56, about one second after the airplane would have broken out of the reported 3,500 ft cloud layer. Both the captain and the first officer subsequently commanded ANU elevator until impact. (The normal load factor recorded by the FDR in Figure 6 is greater than 4g right before impact.)
It now appears that the 'leaked' info from months ago posted on earlier threads ago was from good sources.
Another perfectly good airplane flown into the ground/water due to 'human factors'?
Subject: Houston Amazon 767 Crash 23 Feb 19
From the net, courtesy of a reliable source.… [i.e. Now, this is no s**t... - Airbubba]
Just FYI… we’ve heard the full cockpit audio and seen the data. Here’s... what really happened (name redacted to protect the innocent!):
During the approach, at about 6,000 FT (being flown by the first officer), the Captain reached around the throttle quadrant to extend the flaps to the next position after being called to do so by the first officer (pilot flying)… very normal.
In many aircraft including the 767, that’s a very odd/difficult repositioning of your hand (from the left seat, all the way around to the right side of the center console), and requires intimate familiarity and slow deliberate motion to do successfully.
Well in any case, it was not done so this time. The captain accidently hit the “go around” switch while bringing his hand around for the flaps, which brought both engines up to full power. In the landing configuration, as this aircraft was transitioning into, that obviously causes a vast increase in lift… and the first officer (pilot flying) used everything he had to force the nose back down.
Still not sure why that occurred, as the crew should have just “gone around” and tried it again when properly configured… but they did not. And that started in motion a chain of events that lead to tragedy.
As the First Officer over-rotated downward, again with the engines at full power, the aircraft quickly accelerated and approached something we’re all trained to handle (at least in good training environments)… an “upset recovery”, countered by NON-AUTOMATION and basic “stick and rudder skills”.
This captain however, in turn, grabbed the controls without using positive command (“I’ve got”, “My aircraft”, or anything normally done), and countered the F/O’s control input by completely hauling his control column full aft… remember, while the F/O is pushing full forward.
In the process of doing that, he broke the “shear pin” on his control column (a device/mechanical safety interlock used to separate a control column from the “innards” of the control architecture in the event one control column is doing something it should not)… and that occurred here.
The captain, a few seconds later, now accelerating downward out of the control envelope of the 767 (remember, all of this started at 6000 FT and probably took less time to get to the fatal point than it did to read this far), recognizes the has no control column and then asks the F/O to pull up, get the nose up, or something to that affect. It isn’t 100% clear what he says.
The F/O then tries to pull aft on his column (going from full forward to full aft), but isn’t getting the response he needs, because the aircraft is out of the envelope of controllability and the controls are “air-loaded” in position.
At about 2000 FT, eventually the trim motors are able to start overcoming the air-load, and the aircraft begins to attempt to arrest its rate of descent… but alas it’s far too little, far too late, and the aircraft impacts about 30-40 degrees nose down, with what is believed to be about 4-5000 FT / minute rate of descent.
All during this time the throttles aren’t touched until somewhere during that last few seconds of flight… which is believed to be what enabled the trim motors to start working. Unclear who does it, and no audio indicates who it was.
Just FYI… we’ve attempted in our 767 simulators to recover from the event with the exact same setup, and thus far we’ve only had success when starting at 8000’ or higher… meaning we are fully established in the “out of control” position at 8000’, recognize it by then, and initiate recovery starting at 8000’.
These guys started the whole thing at 6000’ and were much lower when a true recovery attempt was initiated. No chance, and just shows you how quickly you can get “out of the envelope” when you don’t follow procedure, try some completely erroneous recovery technique, and don’t have a clue what you’re doing.
So many things went wrong with crew coordination, basic flying skills, aircraft envelope awareness, basic procedures, and such… that this will likely go down as one of the absolute worst “pilot error” events ever.
It needs to have serious impact throughout the Amazon flying circus (and associated partnerships), and show people that Jeff Bezos’ attempt to push the envelope at lower cost, all things else be damned, doesn’t apply to aviation.
This accident no doubt was absolutely horrible, and three people lost their lives…one of them (the jumpseater) through absolutely no fault of his own. But making an approach into Houston, TX, it could have been so much worse. In another few miles, they would have been over major population centers and who knows what would have happened then.
Know your aircraft. Know your procedures. And for God sakes, just FLY! It’s not a video game!
Relayed by your PJP Editor
Bert Botta
Aviation Writer
PJPFBO Editor
Email: bert@privatejetpilots
From the net, courtesy of a reliable source.… [i.e. Now, this is no s**t... - Airbubba]
Just FYI… we’ve heard the full cockpit audio and seen the data. Here’s... what really happened (name redacted to protect the innocent!):
During the approach, at about 6,000 FT (being flown by the first officer), the Captain reached around the throttle quadrant to extend the flaps to the next position after being called to do so by the first officer (pilot flying)… very normal.
In many aircraft including the 767, that’s a very odd/difficult repositioning of your hand (from the left seat, all the way around to the right side of the center console), and requires intimate familiarity and slow deliberate motion to do successfully.
Well in any case, it was not done so this time. The captain accidently hit the “go around” switch while bringing his hand around for the flaps, which brought both engines up to full power. In the landing configuration, as this aircraft was transitioning into, that obviously causes a vast increase in lift… and the first officer (pilot flying) used everything he had to force the nose back down.
Still not sure why that occurred, as the crew should have just “gone around” and tried it again when properly configured… but they did not. And that started in motion a chain of events that lead to tragedy.
As the First Officer over-rotated downward, again with the engines at full power, the aircraft quickly accelerated and approached something we’re all trained to handle (at least in good training environments)… an “upset recovery”, countered by NON-AUTOMATION and basic “stick and rudder skills”.
This captain however, in turn, grabbed the controls without using positive command (“I’ve got”, “My aircraft”, or anything normally done), and countered the F/O’s control input by completely hauling his control column full aft… remember, while the F/O is pushing full forward.
In the process of doing that, he broke the “shear pin” on his control column (a device/mechanical safety interlock used to separate a control column from the “innards” of the control architecture in the event one control column is doing something it should not)… and that occurred here.
The captain, a few seconds later, now accelerating downward out of the control envelope of the 767 (remember, all of this started at 6000 FT and probably took less time to get to the fatal point than it did to read this far), recognizes the has no control column and then asks the F/O to pull up, get the nose up, or something to that affect. It isn’t 100% clear what he says.
The F/O then tries to pull aft on his column (going from full forward to full aft), but isn’t getting the response he needs, because the aircraft is out of the envelope of controllability and the controls are “air-loaded” in position.
At about 2000 FT, eventually the trim motors are able to start overcoming the air-load, and the aircraft begins to attempt to arrest its rate of descent… but alas it’s far too little, far too late, and the aircraft impacts about 30-40 degrees nose down, with what is believed to be about 4-5000 FT / minute rate of descent.
All during this time the throttles aren’t touched until somewhere during that last few seconds of flight… which is believed to be what enabled the trim motors to start working. Unclear who does it, and no audio indicates who it was.
Just FYI… we’ve attempted in our 767 simulators to recover from the event with the exact same setup, and thus far we’ve only had success when starting at 8000’ or higher… meaning we are fully established in the “out of control” position at 8000’, recognize it by then, and initiate recovery starting at 8000’.
These guys started the whole thing at 6000’ and were much lower when a true recovery attempt was initiated. No chance, and just shows you how quickly you can get “out of the envelope” when you don’t follow procedure, try some completely erroneous recovery technique, and don’t have a clue what you’re doing.
So many things went wrong with crew coordination, basic flying skills, aircraft envelope awareness, basic procedures, and such… that this will likely go down as one of the absolute worst “pilot error” events ever.
It needs to have serious impact throughout the Amazon flying circus (and associated partnerships), and show people that Jeff Bezos’ attempt to push the envelope at lower cost, all things else be damned, doesn’t apply to aviation.
This accident no doubt was absolutely horrible, and three people lost their lives…one of them (the jumpseater) through absolutely no fault of his own. But making an approach into Houston, TX, it could have been so much worse. In another few miles, they would have been over major population centers and who knows what would have happened then.
Know your aircraft. Know your procedures. And for God sakes, just FLY! It’s not a video game!
Relayed by your PJP Editor
Bert Botta
Aviation Writer
PJPFBO Editor
Email: bert@privatejetpilots
The “thump” was the Jumpseater bouncing off the ceiling. The FO had a history of doing this. He was terminated from a previous airline according to a very reliable source. HR is in charge of all pilot hiring at atlas. They hit -4 g’s.
this from the boxes folks, heard the same thing from my insider connection, jumpseater thrown from under his unfastened belt, Captain sheared the control breakaway pulling so hard to override the FO who had his column forward, it is thought as flaps were called for, somehow the Capt inadvertently hit the TOGA levers, which then caused TOGA to activate when flaps "1" were selected, the pitch and startle factor caused the FO to aggressively move his controls nose down, with the captain fighting him to no avail, when the aircraft came clear of the clouds then the FO made some exclamation and began to pull back on the controls, but apparently not aggressively enough , I was not privy to the actual conversation on the CVR, this account was heavily redacted, might be a bit before all the story is heard, the word I heard used to describe it was "shocking"
my source dried up, refuses to talk about it...NOT an airplane issue is all thats being said
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It's the records, interviews, CVR and FDR analyses and other documentation of evidence collected in an NTSB accident investigation.
From the media release in the first post on this thread:
From the media release in the first post on this thread:
The docket includes more than 3,000 pages of factual reports that cover various aspects of the investigation, including operations, survival factors, human performance, air traffic control, aircraft performance, and includes the cockpit voice recorder transcript, sound spectrum study, and the flight data recorder information. The docket also includes interview transcripts, photographs, and other investigative materials.
The docket contains only factual information collected by NTSB investigators; it does not provide the final report, analysis, findings, recommendations, or probable cause determinations. No conclusions about how or why the crash occurred should be drawn from the information within the docket. Analysis, findings, recommendations, and probable cause determinations related to the crash will be issued by the NTSB in a final report at a later date.
The docket contains only factual information collected by NTSB investigators; it does not provide the final report, analysis, findings, recommendations, or probable cause determinations. No conclusions about how or why the crash occurred should be drawn from the information within the docket. Analysis, findings, recommendations, and probable cause determinations related to the crash will be issued by the NTSB in a final report at a later date.