Tragic Crash of Atlas Air Flight 3591 Exposes Gaps in Pilot Safety Systems and Legislation

On February 23, 2019, a tragic incident occurred that shocked the aviation world and brought to light serious gaps in both pilot safety systems and legislation that were meant to protect lives. Atlas Air Flight 3591, a domestic cargo flight traveling from Miami International Airport to George Bush Intercontinental Airport in Houston, tragically crashed in the marshlands near Trinity Bay, Texas, killing all three pilots on board. 

The accident occurred just 31 seconds after a series of events unfolded, and the causes of this disaster highlight the flaws in the existing safety systems, as well as in the screening process for pilots.

A Chain of Events Leading to Tragedy

The flight, which began as a routine cargo transport, soon turned into a nightmare after the inadvertent activation of the aircraft's TO/GA (Takeoff/Go-Around) button. This seemingly small malfunction triggered a series of actions that led to a crash that could have been prevented had critical systems been in place.

It all began when the aircraft was in the midst of its descent towards Houston. During the flight, the first officer and captain were managing the approach, when a cold front moved in unexpectedly, bringing along storm clouds and turbulence.

The aircraft, a Boeing 767, was set to approach one of the westerly-facing runways in Houston. However, as they neared the city, the pilots had to navigate through increasingly difficult weather conditions, including heavy precipitation and winds.

Despite these challenges, the pilots remained focused on the task at hand. The aircraft’s descent was initially smooth, and the pilots followed the typical protocols for managing the approach. But then, as they passed through the storm clouds and the first officer struggled with his instruments, things began to take a turn for the worse.

The Pilot’s Troubling History

A critical factor that contributed to this crash was the history of the first officer, whose training and past issues were not properly addressed before he was hired by Atlas Air. The first officer, who was 44 years old at the time, had a very troublesome training history. He had previously resigned from two airlines, Air Wisconsin and CommuteAir, after failing their initial training programs.

However, in his application to Atlas Air, he failed to disclose these resignations, and instead, claimed that he had been studying for a college degree during that time. This omission, which would have been flagged by the Pilot Records Database (PRD) had it been implemented at the time, allowed him to slip through the cracks and secure a job as a first officer with Atlas Air.

This hidden history of training failures should have been a red flag, especially given that the Pilot Records Improvement Act (PRIA), which had been implemented in 1996, was designed to ensure that such issues were identified before hiring a pilot.

Unfortunately, the PRIA system relied on the honesty of applicants, and as seen in this case, it was easily bypassed. Despite his past failures, the first officer managed to join Atlas Air, where his struggles with training continued, but were not adequately addressed.

His performance during his initial training at Atlas was concerning. He struggled with basic procedures, which led to repeated failures in flight simulation training. Even when he passed his flight tests, it was clear that he was not performing at the level expected of a commercial pilot. His inability to properly handle unexpected situations was a significant concern that went unnoticed until it was too late.

A Malfunction That Set Everything in Motion

The actual cause of the crash began with the inadvertent activation of the TO/GA button. This malfunction caused the aircraft to pitch up suddenly, a reaction that was not expected by the pilots. The first officer, likely distracted by the turbulence and the ongoing weather issues, did not recognize the issue immediately.

As the aircraft began to climb unexpectedly, the first officer, reacting to the situation with his typical response to stress—pressing buttons and making random inputs on the flight controls—caused the aircraft to enter an accelerated descent.

This kind of reaction is a textbook example of a situation where a pilot’s response to stress can worsen an already dangerous situation. The first officer’s previous training issues, which included failing to deal with unexpected situations calmly, were now having deadly consequences. The aircraft, in a matter of seconds, began descending rapidly, and the pilots were unable to regain control.

The Captain’s Response

As the first officer initiated the incorrect response to the malfunction, the captain was distracted by other tasks, including reviewing weather information and making adjustments to the flight path.

This momentary lapse in attention meant that the captain did not notice the first officer’s erratic control inputs and failed to intervene until it was too late. When the descent rate increased rapidly, the captain tried to take control of the aircraft, but it was clear that the damage had already been done.

The two pilots were now fighting against each other’s control inputs, with the first officer pushing the nose down and the captain trying to pull it up. This confusion and lack of coordination between the two crew members led to a terrifying sequence of events that culminated in the crash. The pilots’ delayed reactions, compounded by the lack of proper training and the stress of the situation, resulted in a catastrophic loss of control.

The Human Factor

One of the key issues that came to light after the crash was the psychological and behavioral tendencies of the first officer. His history of stress-induced errors, where he would randomly push buttons in an attempt to appear active rather than thinking critically about the situation, contributed significantly to the disaster. This type of behavior, when combined with the stress of the moment, led to an irreversible chain of events.

Moreover, the lack of an effective backup system to monitor the crew’s actions, as seen in the case of the captain’s delayed response, further exacerbated the situation. It highlighted the need for a more robust and proactive approach to pilot performance monitoring, especially in high-stress scenarios.

Investigations and Findings

Following the crash, the National Transportation Safety Board (NTSB) launched an investigation into the circumstances surrounding Atlas Air Flight 3591. The findings pointed to multiple factors that contributed to the disaster, including the failure of the PRIA system to identify the first officer’s problematic training history, the inadequate response to the TO/GA button malfunction, and the lack of coordination between the two pilots.

The NTSB’s final report was critical of Atlas Air’s hiring practices and the FAA’s failure to implement the Pilot Records Database (PRD) in time to prevent the hiring of a pilot with such a troubling history. The report also recommended significant changes to pilot performance monitoring and the implementation of more effective safety systems to prevent similar incidents in the future.

A Tragic Reminder

The crash of Atlas Air Flight 3591 serves as a tragic reminder of the importance of thorough pilot screening, adequate training, and the need for immediate response to unexpected malfunctions. This incident should never have happened, and the failure to address these issues has cost three lives.

As the aviation industry continues to evolve, it is crucial that the lessons learned from this disaster be applied to ensure that future generations of pilots are adequately prepared to handle the challenges of flying.

In the aftermath of this tragedy, the aviation community must strive to implement the necessary changes to improve safety standards, and most importantly, to honor the memory of those who lost their lives in this preventable crash.