Saturday, March 02, 2019

Atlas Air, Boeing 767-375, N1217A: Fatal accident occurred February 23, 2019 in Trinity Bay, Baytown, Chambers County, Texas

Atlas Air First Officer Conrad Jules Adrian Aska

Mesa Airlines Capt. Sean Archuleta
(non-revenue jump seat pilot)

The Captain

Ricky Blakely 

The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entity: 

Federal Aviation Administration / Flight Standards District Office; Houston, Texas

Aviation Accident Preliminary Report - National Transportation Safety Board:

Investigation Docket - National Transportation Safety Board:

Location: Trinity Bay, TX
Accident Number: DCA19MA086
Date & Time: 02/23/2019, 1239 CST
Registration: N1217A
Aircraft: Boeing 767
Injuries: 3 Fatal
Flight Conducted Under: Part 121: Air Carrier - Non-scheduled 

On February 23, 2019, at 1239 central standard time, Atlas Air flight 3591, a Boeing 767-375BCF, N1217A, entered a rapid descent from 6,000 ft and impacted a marshy bay area about 40 miles southeast of George Bush Intercontinental Airport (KIAH), Houston, Texas. The two pilots and one nonrevenue jumpseat pilot were fatally injured. The airplane was destroyed and highly fragmented. The airplane was operated as a Title 14 Code of Federal Regulations Part 121 domestic cargo flight, which originated from Miami International Airport (KMIA), Miami, Florida, and was destined for KIAH.

Investigative updates can be found at

Aircraft and Owner/Operator Information

Aircraft Make: Boeing
Registration: N1217A
Model/Series: 767 375
Aircraft Category: Airplane
Amateur Built: No
Operator: Atlas Air
Operating Certificate(s) Held: Supplemental

Meteorological Information and Flight Plan

Conditions at Accident Site:
Condition of Light:
Observation Facility, Elevation:
Observation Time:
Distance from Accident Site:
Temperature/Dew Point:
Lowest Cloud Condition:
Wind Speed/Gusts, Direction: / ,
Lowest Ceiling:
Altimeter Setting:
Type of Flight Plan Filed:
Departure Point:

Wreckage and Impact Information

Crew Injuries: 2 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 1 Fatal
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 3 Fatal
Latitude, Longitude:

The National Transportation Safety Board made public more than 3,000 pages of its investigation into Atlas Air Flight 3591 on December 19. 

Three people, including two Atlas Air employees and one Mesa Airlines employee riding in the plane's jump seat, died in the February 23 crash. Called CustomAir Obsession, the plane was contracted to Atlas Air by Amazon, and was carrying Amazon and US Postal Service cargo. 

The NTSB did not release a final report or conclusion with its opening of the public docket. But, interviews with myriad executives, pilots, and training officials reveal a disturbing truth about safety standards at Atlas Air, which contracted 20 of its 112 planes to Amazon as of February. Amazon also owns 20% of Atlas' stock warrants.

Two pilots were at the helm of Atlas Air Flight 3591, which it crashed on February 23 in Houston, Texas. The captain was Ricky Blakely, who had worked for Atlas Air since September 2015. He had 11,000 hours of flight experience and 1,250 hours of experience with the Boeing 767.

Conrad Jules Aska, the first officer, or copilot, had 5,000 hours total flight experience and about 520 hours of experience with the Boeing 767. Mesa Airlines Capt. Sean Archuleta, who was riding in the jump seat, also died in the crash.

What the NTSB documents showed

The NTSB investigators found numerous problems relating to Atlas' pilot hiring practices — specifically around Aska. The first officer previously worked at Mesa Airlines, Air Wisconsin, and CommutAir. At the latter two airlines, the NTSB found that he failed to finish training and was promptly flushed out of those carriers. He spent just a month at CommutAir. 

Before working at Atlas, Aska was a first officer at Mesa. He tried but could not upgrade from FO to captain on the Embraer 175 regional jet at the Phoenix-based regional carrier. Check airmen, or pilot trainers, at Mesa raised several concerning flags to NTSB investigators.

Captain Paul Allred, Mesa Air check airman, told the NTSB that Aska was "one of the worst he'd ever seen, probably a 2" out of 10 in terms of piloting skills.

Meanwhile, Captain Leigh Lawless, another Mesa Air check airman, said Aska had a "lack of understanding of how unsafe he was."

NTSB investigators wrote, from talking with Lawless, that Aska "was making very frantic mistakes, lots and lots of mistakes, and did a lot of things wrong but did not recognize this was a problem. He thought he was a good pilot never had any problems and thought that he should be a captain. He could not evaluate himself and see that he did not have the right stuff."

Aska later applied to Atlas Air. He did not disclose his short stretches at Air Wisconsin or CommutAir while applying. 

An Atlas spokesperson told Business Insider that the company's employees "meet or exceed all government safety standards. Atlas pilot training includes multiple reviews, evaluations and proficiency checks to comply with FAA regulations."

The spokesperson, who said Atlas is cooperating with the NTSB investigation, added that Atlas has enhanced employee training and candidate background checks since the crash.

Quick scaling

Scott Anderson, senior director of flight procedures, training, and standards at Atlas, told NTSB investigators that the airline would not have hired Aska had they known about his failures to pass trainings at those two airlines.

The pilot told Atlas during the hiring process that he was involved in real estate and freelance work during the two-year gap of his resume, which Atlas Air believed at the time. 

"Any idea why Atlas didn't know about that -- those training difficulties?" the NTSB investigator asked.

"I don't know," Anderson responded. "I don't know."

Meanwhile, aviation attorney Steven Marks — who is representing Aska in a federal lawsuit against Amazon, Atlas, and other parties — said every proficiency check and airline an applicant works for is disclosed by the Federal Aviation Administration when they apply to a new airline. "It is a wakeup call to start paying attention more to the operations and not compromise safety at the expense of growth," Marks told Business Insider. 

Additionally, Anderson said Aska had several remedial trainings while at Atlas. Asked why he did not receive additional remedial training or retribution, Anderson referred to "mitigating circumstances" — including the presence of FAA officials observing his type rating, which could have made him more nervous and his performance worse, as well as damage to his home during Hurricane Irma.

Anderson alluded in his interview to the quick scaling of Atlas Air in recent years. That growth is largely due to its partnership with Amazon, which it began working with in 2016.

Business Insider spoke with 13 pilots who work at Atlas Air and ATSG, Amazon's other air cargo partner, earlier this year. Those pilots described how a culture of quick growth at Atlas, due to the Amazon contract, which contributed to a decline in safety and hiring standards.

"I am concerned anytime that new entrants into aviation particularly carrying packages or goods enter a market where their background has been essentially trying to cut costs to make money," Jim Hall, who led the National Transportation Safety Board (NTSB) from 1994 to 2001, previously told Business Insider, referring specifically to Amazon.

"Cutting costs in aviation causes deaths and accidents."

Original article ➤

Captain Ricky Blakely 

Atlas Air First Officer Conrad Aska, 44, was killed when Atlas Air flight 3591 crashed into the shallow waters of Trinity Bay on February 23rd, 2019, near Anahuac. His body was recovered that day.

Sean Archuleta 36, a jump seat rider, was killed when Atlas Air flight 3591 crashed into the shallow waters of Trinity Bay on February 23, 2019, near Anahuac. His body was recovered the next day.

Accident No: DCA19MA086
Accident Type: Office of Aviation Safety
Location: Baytown, Texas
Date: 2/23/2019

​The NTSB launched a Go-team to investigate the February 23, 2019 Atlas Air #3591 crash into Trinity Bay in Baytown, TX.

NTSB Chairman Robert L. Sumwalt accompanied the team and will serve as the principal spokesman on-scene.

See the photos on NTSB Flickr site.

March 12, 2019 - Investigative Update

On February 23, 2019, at 1239 central standard time, Atlas Air flight 3591, a Boeing 767-375BCF, N1217A, entered a rapid descent from 6,000 ft and impacted a marshy bay area about 40 miles southeast of George Bush Intercontinental Airport (KIAH), Houston, Texas. The two pilots and one nonrevenue jumpseat pilot were fatally injured. The airplane was destroyed and highly fragmented. The airplane was operated as a Title 14 Code of Federal Regulations Part 121 domestic cargo flight, which originated from Miami International Airport (KMIA), Miami, Florida, and was destined for KIAH.

The NTSB launched a go-team consisting of an investigator-in-charge from the major investigations division and specialists in structures, systems, powerplants, air traffic control (ATC), and meteorology. Specialists in operations, human factors, maintenance records, and flight recorders supported the investigation from other locations.

Parties to the investigation include the Federal Aviation Administration (FAA), Atlas Air, General Electric (GE) Aviation, Boeing, the International Brotherhood of Teamsters, and the National Air Traffic Controllers Association. The investigative team was also assisted by numerous other federal, state, and local law enforcement and public safety agencies.

The wreckage was situated in a shallow muddy swamp area, and the main debris field was oriented east to west and about 350 yards long by about 200 yards wide (figure 1). One engine and some landing gear components were found beyond the main debris field to the west. Less dense components and a large portion of the cargo floated southward and were recovered up to 20 miles away. The wreckage was highly fragmented and resting in the soft mud in 1-3 ft of water. Recovery of the wreckage was very difficult in the swampy conditions because visibility in the water was poor and the muddy bottom could not support heavy equipment. Airboats, barges, and amphibious equipment was brought in to search for the recorders and retreive the wreckage.

Figure 1. Aerial view of main debris field during recovery operation.
Airboat in top center is retrieving the CVR at the time of this photo.

Air traffic control communications and radar data indicated the flight was normal from Miami to the Houston terminal area. About 12:30 pm 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.

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. (See figure 2.)

Figure 2. National Weather Service NEXRAD weather, white star is accident site.

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 (figure 3).

Figure 3. ADS-B track

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. Shortly after, when the airplane’s 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 (figure 4) 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.

Figure 4. Still frame from security video 

The airplane was manufactured in 1992 as a Boeing 767-375 in a passenger configuration and was equipped with GE CF-6 engines. It was converted to a freighter configuration in 2017. Maintenance records showed the airplane had 91,063 hours and 23,316 cycles at the time of the accident. There were no outstanding airworthiness directives or inoperative items.

Company records indicated that the captain was qualified and current in the airplane and held an FAA airline transport pilot certificate with type ratings for the B757/767 and EMB145. He had a current FAA first class medical certificate with a limitation for corrective lenses. He had worked for Atlas Air since September 2015 and had about 11,000 hours total flight experience with about 1,250 hours of experience in the Boeing 767.

The first officer was qualified and current in the airplane and held an FAA airline transport pilot certificate with type ratings for the B757/767, EMB145, and EMB170/190. He had a current FAA first class medical certificate with a limitation for glasses for near vision. He had worked for Atlas Air since July 2017 and had about 5,000 hours total flight experience with about 520 hours of experience in the Boeing 767.

A cockpit voice recorder (CVR) group was convened and will complete a transcript of the entire event. The CVR transcript will be released when the public docket is opened. Other groups include operations/human factors, ATC, weather, structures, systems, powerplants, and maintenance records. Further groups may be formed as the investigation progresses.

Additional information will be released as warranted.

Those who may have information that might be relevant to the National Transportation Safety Board investigation may contact them by email, and any friends and family who want to contact investigators about the accident should email

NTSB Laboratory Completes Initial Review of Cockpit Voice Recorder, Recovers Flight Data Recorder

March 05, 2019

​Engineers at the National Transportation Safety Board’s Office of Research and Engineering Vehicle Recorder Division completed the initial review of the Atlas Air Flight 3591 cockpit voice recorder Saturday evening and recovered the airplane’s flight data recorder Sunday.

Three people (the two pilots for the flight and a non-revenue jump-seat pilot) died when Atlas Air Flight 3591, a Boeing 767-300 cargo jet, crashed in the muddy marshland of Trinity Bay Feb. 23, 2019, about 40 miles from Houston’s George Bush Intercontinental Airport. The airplane was destroyed. The airplane was carrying cargo for Inc., and the US Postal Service from Miami to Houston.

The condition of the accident site made locating the recorders challenging.

In this photo, taken Saturday in the NTSB laboratory in Washington, an NTSB engineer from the Office of Research and Engineering’s Vehicle Recorder Division inspects memory boards from the cockpit voice recorder of Atlas Air Flight 3591 for signs of damage and water intrusion. Atlas Air Flight 3591 crashed Feb. 23, 2019, about 40 miles from Houston’s George Bush Intercontinental Airport, and the NTSB recovered the airplane’s CVR March 1, 2019. NTSB photo.

Directors from the Office of Research and Engineering and the Office of Aviation Safety conducted an audition of the CVR as part of the NTSB’s ongoing investigation of the accident. 

The audition revealed the following information, which is preliminary and subject to change as the investigation continues: 

  • The length of the recording is approximately two hours and was obtained from a download of a solid-state type cockpit voice recorder.
  • The recording included the final portion of the flight; however, the quality of the audio is poor.
  • There are times during the recording when the content of crew discussion is difficult to determine, at other times the content can be determined using advanced audio filtering.
  • The crew was in communication with air traffic control and were being provided radar vectors for the runway 26L approach into George Bush Intercontinental Airport.
  • Crew communications consistent with a loss control of the aircraft began approximately 18 seconds prior to the end of the recording.

The flight data recorder arrived at the NTSB’s Recorder Lab Sunday at 11:45 p.m. 

The memory module was disassembled, cleaned and dried, and download of the data was achieved Monday afternoon. Initial review of the data revealed:

  • The accident flight was captured, and the FDR contained a total of about 54 hours of data from 17 flights.
  • There were approximately 350 parameters recorded by the FDR detailing the motion of the aircraft and operation of its engines, flight controls and other systems.
NTSB recorder investigators are currently verifying and validating the FDR data, and the NTSB plans to provide a summary in an investigative update in a few days.

Technical experts in the CVR group will convene in the coming week to review the entire recording and produce a transcript of the accident recording. It will be a time-consuming process to complete the transcript.

The CVR group is one of the seven investigative groups established by the Investigator-in-Charge for the accident investigation.

Imagery of the NTSB’s investigation of the accident is available via the NTSB Flickr account at and B-roll is available via the NTSB YouTube Channel at

A few weeks ago a Boeing 767-375 was maneuvering near an airport when it abruptly nosedived and plowed into the ground at tremendous speed, killing everyone aboard. This was not the Ethiopian Airlines crash on March 10 that has transfixed the world, however. It was an American plane, a 767, and its destruction in a muddy bay near Houston remains even more mysterious and, consequently, potentially more disturbing in its long-term implications.

At 12:30 p.m. on February 3, Atlas Air Flight 3591 was near the end of a flight from Miami to Houston’s George Bush Intercontinental Airport, carrying cargo for Amazon and the U.S. Postal Service. Two pilots were at the controls and another was riding as a passenger. A band of stormy weather lay across the route, and as the plane was descending from 8,500 feet, air traffic control advised the pilots to turn left from a northerly heading, in order to get around a band of precipitation. A different controller then said that they’d be given vectors to clear skies. One of the pilots replied, “Okay.”

A few seconds later, the plane hit a patch of rough air. For reasons that are unknown, the flight crew throttled the engines up to full thrust, and then after the plane pitched slightly up, pushed the controls sharply forward until the plane was descending at a 49-degree angle — about what you’d encounter on the steepest of ski runs. The plane kept diving, even as cockpit warning systems called for the pilots to pull up. Security-cam footage shows the plane plummeting from 6,000 feet:

Eighteen seconds after the trouble started, the plane smashed into the muddy waters of Trinity Bay, killing everyone aboard.

A preliminary report by the National Transportation Safety Board on the incident caused a stir when it cited “control input” as the cause for the steep dive. Was this a case of pilot suicide, like the Germanwings pilot who programmed his Airbus A320 to fly into the side of a mountain in 2015? But it’s hard to imagine that, in the midst of trying to maneuver through and around bad weather, a pilot suddenly decided to commit suicide.

A revised version of the NTSB report changed the language to “a nose-down elevator deflection,” which seemed to move responsibility away from the human pilots and raised the possibility that a malfunction, perhaps of the autopilot, could have been responsible. But there are no known autopilot modes that would behave like this.

In online pilot discussion forums, a third idea has been gaining adherents: that the pilots succumbed to a phenomenon called somatogravic illusion, in which lateral acceleration due to engine thrust creates the sensation that one is tipping backward in one’s seat. The effect is particularly strong when a plane is lightly loaded, as it would be at the end of a long flight when the fuel tanks are mostly empty, and in conditions of poor visibility, as Atlas Air 3591 was as it worked its way through bands of bad weather.

The idea is that perhaps one of the pilots accidentally or in response to wind shear set the engines to full power, and then believed that the plane had become dangerously nose-high and so pushed forward on the controls. This would cause a low-g sensation that might have been so disorienting that by the time the plane came barreling out of the bottom of the clouds there wasn’t enough time to pull out of the dive.

It has been speculated that this might have been the cause of another bizarre and officially unsolved accident from three years ago: Flydubai Flight 981, which crashed 2016 in Rostov-on-Don, Russia. That plane had been returning Russian vacationers from Dubai when it encountered bad weather and was unable to land. After circling for an hour and a half, the pilots attempted to land, then aborted the attempt, came around again for another attempt, and then aborted again. After climbing sharply, the plane pitched forward into a steep dive and smashed into the edge of the runway, killing all 62 people aboard.

The crash of two 737 Max airplanes — Ethiopian Airlines Flight 302 and Lion Air Flight 610 — in quick succession is horrific, but in a way, this kind of disaster shows how the system is supposed to work: a mishap occurs, officials determine what happened, and then the problem is fixed so that future air travel will be safer. While it’s still too early to draw any kind of conclusions about Atlas Air 3591, the possibility exists that a firm conclusion will never be drawn — and if it is, the cause could turn out not to be a design flaw or software malfunction that can be rectified, but a basic shortcoming in human perception and psychology that cannot be fixed as long as humans are entrusted with the control of airplanes.

Original article can be found here ➤

The Wall Street Journal
By Andy Pasztor
March 15, 2019 4:06 p.m. ET

Federal air-crash investigators suspect that pilot errors, rather than aircraft malfunctions, led to an Atlas Air cargo plane’s nosedive near Houston in February that killed all three people on board, according to people familiar with the details.

National Transportation Safety Board experts, these people said, are focusing on a likely sequence of events that started with the crew of the Boeing Co. 767 approaching Houston’s George Bush Intercontinental Airport on Feb. 23 inadvertently commanding dramatically increased engine thrust. Turbulent air could have jostled the arm of one of the pilots, causing the engines to rev up to takeoff power, one of these people said.

The sudden surge in thrust, which the safety board disclosed in an earlier factual update, forced the nose of the plane to pitch upward and startled the cockpit crew, according to these people. Almost immediately, according to the preliminary data released by the safety board, the crew responded by sharply pushing down the nose of the aircraft.

The board previously said the nose was pointed downward at a 49-degree angle with the plane still about 30 miles from the airport, creating a much steeper descent than a normal landing approach.

The seemingly disoriented crew failed to regain control—despite commands to pull up from the jet’s high-speed dive—and the wide-body plane plowed into a marshy area.

The safety board said the crew had the required training and medical certificates.

The safety board hasn’t issued any final conclusions, and the leading theory currently pursued by investigators could change as more information is developed. A spokesman for the board said it had no comment beyond the factual update released earlier. Boeing had no immediate comment.

Atlas Air Worldwide Holdings Inc. and the union representing its pilots both declined to comment, citing the ongoing investigation.

But at this point, such cockpit slipups are considered the most likely cause of the crash. The plane was skirting around some storm cells before the plunge, but people familiar with the details said the turbulence didn’t cause any structural damage or lead any system to malfunction.

In its update, the safety board said the “engines increased to maximum thrust” as the plane was flying at roughly 6,000 feet. After a brief nose-up movement, according to the update, the Boeing 767 entered a steep descent in a “generally wings-level attitude until impact with the swamp.”

Many airline and aerospace industry officials have watched the probe closely because the 767 model is widely used as a passenger jet around the globe.

The Atlas Air flight, en route to Houston from Miami, was flying cargo for Inc.

The last fatal U.S. airliner crash also was a cargo flight. In 2013, a United Parcel Service Inc. Airbus A300 slammed into hill while approaching to land in Birmingham, Ala., killing both pilots. The safety board determined that a series of pilot errors and violations of safety procedures caused that accident. The aircraft descended too quickly toward a runway shrouded by clouds, and the pilots waited until the last seconds to try to initiate a go-around.

Original article can be found here ➤

Rick Blakely, Conrad Aska, Sean Archuleta 

In this photo taken February 24th, 2019, NTSB senior investigator Jim Hookey (on right) with Dan Kemme of GE aviation, examines wreckage recovered from the scene of the February 23rd, 2019, cargo jet crash in Texas.

In this photo, NTSB investigators along with representatives from Boeing and Texas Game Warden searching Trinity Bay for recorders from the cargo jet crash in Texas using pinger locator equipment to listen for the underwater locator beacon. 

National Transportation Safety Board investigators on shoreline of Trinity Bay examining wreckage.

The Anahuac Chamber of Commerce placed three memorial crosses in 

Video captured February 23rd, 2019, shows the final moments of doomed Atlas Air flight 3591 which crashed into Trinity Bay.

The Chairman of the National Transportation Safety Board Robert Sumwalt talks about the wreckage of a Boeing 767-375 contracted by Amazon that crashed into Trinity Bay.

Perrye Turner with the FBI talks about the wreckage of a Boeing 767 cargo jetliner contracted by Amazon that crashed into Trinity Bay.

The Chambers County Sheriff Brian Hawthorne talks about the wreckage of a Boeing 767 cargo jetliner contracted by Amazon that crashed into Trinity Bay. 

Don Dalton talks about his friend/roommate who died in the Boeing 767-375.

Chambers County Sheriff Brian Hawthorne gives an update on a plane crash in Trinity Bay during a news conference on February 23rd, 2019. 

Members of the Houston Police Department's Dive Team perform a grid search for wreckage of Atlas Air flight 3591, which crashed into Trinity Bay on February 23rd, 2019.

Wreckage from Atlas Air flight 3591 is seen floating in Trinity Bay after the cargo plane crashed February 23rd, 2019.

Pilot Sean Archuleta, First Officer Conrad Jules Aska of Antigua and Captain Ricky Blakely of Indiana.

First Officer Conrad Jules Aska