Story ID: 
NTSB Cites Pilot Actions in Atlas Crash
By: Matt Thurber
Caption: The crash of an Atlas Air 767 in 2019 resulted from inadvertent activation of the airplane's go-around mode and the pilots' incorrect response.
Word Count: 1140
The NTSB has released the probable cause of the crash of an Atlas Air Boeing 767 on Feb. 23, 2019, near Houston, citing the first officer (FO) for “inappropriate response” to inadvertent activation of the autopilot’s go-around mode and the captain for not adequately monitoring the flight path of the airplane and for not taking control. Both pilots and a pilot flying jumpseat died in the accident.

The 767 descended rapidly from about 6,000 feet, 32 seconds after the FO inadvertently switched on the airplane’s go-around mode. According to the NTSB, “Within seconds of go-around mode activation, manual elevator control inputs overrode the autopilot and eventually forced the airplane into a steep dive from which the crew did not recover.”

The probable cause of the accident “was the inappropriate response by the first officer as the pilot flying to an 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 from which the crew did not recover. Contributing to the accident was the captain’s failure to adequately monitor the airplane’s flight path and assume positive control of the airplane to effectively intervene. Also contributing were systemic deficiencies in the aviation industry’s selection and performance measurement practices, which failed to address the first officer’s aptitude-related deficiencies and maladaptive stress response. Also contributing to the accident was the Federal Aviation Administration’s failure to implement the pilot records database in a sufficiently robust and timely manner.”

The full accident report outlined problems with the FO’s past experience, which included checkride failures and the need for remedial training in order to pass the oral examination for his 767 type rating, as well as remedial fixed-based simulator training before starting full-flight simulator (FFS) training. 

The 767 FFS training was restarted from the beginning after the first two sessions, in part because there wasn’t enough “available seat support” to continue the training. The FO’s simulator partner had “complained that he was being held back by the FO.” After completing six FFS training sessions, the training had to be stopped because of a hurricane. Weeks later, training resumed, but the FO failed his type rating checkride, according to the NTSB, “due to unsatisfactory performance in CRM, threat and error management, non-precision approaches, steep turns, and judgment. During a postaccident interview, the Atlas check airman who was the FO’s examiner said the FO was very nervous, had ‘very low’ situational awareness, overcontrolled the airplane, did not work well with the other pilot, omitted an emergency checklist during an abnormal event, and exceeded a flap speed. The examiner said the FO was not thinking ahead, and, when he realized that he needed to do something, he often did something inappropriate, like push the wrong button. The examiner said the FO’s performance was so poor that he worried that the FO would be unable to ‘mentally recover’ enough to complete the course.”

After receiving more remedial training, the FO passed the type rating checkride.

The NTSB listed further deficiencies in the FO’s past, but not all of this information was disclosed or made available to Atlas Air nor to the many other airlines where he previously worked.

From June 2008 to June 2010, he worked as an FO at Air Turks and Caicos, but then was furloughed. He flew for CommutAir from May to June 2011, but “Did not complete FO initial training for de Havilland DHC-8 and resigned citing ‘lack of progress in training.’” 

From April to August 2012, he worked for Air Wisconsin Airlines. According to the NTSB, “Did not complete FO initial training for Canadair Regional Jet and resigned citing personal reasons.”  He then flew as FO in an EMB 120 for Charter Air Transport, from February 2013 to March 2014.

In 2014, the FO failed oral and practical tests for his Airline Transport Pilot certificate in the Embraer ERJ145 at Trans States Airlines, but he later successfully retested. “He was graded unsatisfactory on a line check in August and resigned citing personal reasons.”

From February 2015 to July 2017, he flew as FO in an ERJ175 at Mesa Airlines but then “unsuccessfully attempted to upgrade to captain in May 2017 and resigned (citing ‘career growth’) to accept a position with Atlas.”

According to the NTSB, “When the FO applied for a job at Atlas, he did not disclose that he had worked for Air Wisconsin and CommutAir or that he did not complete initial training at either airline. He also did not disclose to Trans States Airlines when he applied for a job there that he had previously worked for and did not complete initial training at Air Wisconsin.”

The NTSB interviewed instructors and check airmen at Mesa Airlines and Air Wisconsin.

“According to one check airman at Mesa Airlines, the FO could explain things well in the briefing room and performed some expected tasks well in the simulator. However, when presented with something unexpected in the simulator, the FO would get extremely flustered and could not respond appropriately to the situation. She said that when the FO did not know what to do, he became extremely anxious and would start pushing a lot of buttons without thinking about what he was pushing, just to be doing something. She noted that the FO lacked an understanding of how unsafe his actions were, and he could not see why he should not be upgraded to a captain.

“Another check airman at Mesa said the FO’s stick and rudder skills were weak, and he also struggled with basic flight management system tasks. This check airman described the FO’s piloting performance as among the worst he had ever seen and noted that the FO tended to have an excuse for each of his poor performances, such as blaming his simulator partner, his instructor, or the hotel. 

“A third check airman at Mesa said that the FO had weak situational awareness, did not realize what was going on with the airplane at times, and had difficulty staying ahead of the airplane. She said the FO was completely unaware that he lacked skills, unwilling to accept feedback, and unhappy with her about his failure to upgrade to captain. 

“An instructor who taught cockpit procedures on the flight training devices at Air Wisconsin Airlines recalled that during one emergency procedures training scenario, the FO made abrupt control inputs that triggered the stick shaker and overspeed alerts. The instructor said that instead of staying engaged in the scenario and addressing the problem with his training partner, the FO just stopped what he was doing and turned around and looked at the instructor. The instructor found this reaction highly unusual.”