Discussion: Why Do We Investigate Aircraft Accidents? Peers Review 2

Provide a classmate review on their discussion topic :

esearch any current event (within the past 24 months) associated with an aircraft/Unmanned Aerial System incident, accident, and/or aviation safety study. Discuss the implications for industry, and/or the role of the investigative and regulatory bodies associated with these events. Be sure to differentiate the roles and responsibilities of the different agencies and apply NTSB terminology, as appropriate. 



Classmate post that you need to post comment/ review on:

For this discussion post, I chose a fatal accident that happened two years ago involving an Atlas Air flight. It caught me by surprise because I hadn’t heard about it despite it involving a well-known carrier. It shares similarities to the Colgan Air crash in 2010 in that there were pilot discrepancies in one of the pilot’s records (in this case the FO) that were not known to the employer because of a lack of a central pilot records database. 

Accident Overview and Probable Cause

On February 23, 2019, at 1239 CST, Atlas Air Flight 3591, a Boeing 767, was destroyed after it rapidly descended from an altitude of about 6,000ft MSL and crashed into Trinity Bay, Texas as it was approaching George Bush Intercontinental Airport (IAH) in Houston, Texas. All three persons on board – the captain, the first officer, and a nonrevenue pilot on the jumpseat – were killed.

The first officer was the pilot flying, while the captain was the pilot monitoring. The autopilot and autothrottle were engaged and remained engaged for the remainder of the flight. Weather information about a minute prior to the crash indicated that the airplane was about to penetrate the leading edge of a cold front, within which windshear and IMC conditions were likely. The flight data recorder data showed that during this time, aircraft load factors recorded were consistent with the aircraft’s encounter with light turbulence. At 1238:31, with the flight about 40 miles from IAH and descending through 6,300ft to the 3,000ft MSL target, the airplane’s go-around mode was activated. No go-around callout was made by either pilot to indicate intentional activation.

Within seconds of the go-around activation, manual elevator control inputs overrode the autopilot and eventually forced the airplane into a steep dive from which the crew did not recover. Only 32 seconds elapsed between the go-around mode activation and the airplane’s ground impact (NTSB, 2020).

Probable Cause

The NTSB (2020) notes that the accident’s probable cause was the first officer’s inappropriate response, as the pilot flying, to the 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.

Contributing factors were:

  • The captain’s failure to adequately monitor the airplane’s flight path and assume positive control of the airplane to effectively intervene
  • The systemic deficiencies in the aviation industry’s selection and performance measurement practices (which failed to address the FO’s aptitude-related deficiencies and maladaptive stress response)
  • The FAA’s failure to implement the pilot records database in a sufficiently robust and timely manner (p. vii)

The NTSB’s animation of the crash sequence can be found here:https://www.youtube.com/watch?v=GsSNr5DR840

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