Atlas Air 3591

Atlas Air 3591 was a Boeing-767 Freighter, operating as an Amazon Prime delivery, flying from Miami, FL to Houston, TX on February 24, 2019. On board were the two pilots, and one jump-seater. As they were nearing Houston, and making those descent and turning maneuvers required to place themselves in sequence for landing, they suddenly pitched down, and dove into the North end of Trinity Bay, hitting the water at a very high speed and descent rate. All three men onboard were killed.

Here is what happened, as determined by the subsequent investigation. The First-Officer was the Pilot-Flying as the Captain was the Pilot-Monitoring. Air Traffic Control had encouraged them to increase their descent rate, so to allow them to make a favorable turn upon clearing a conflicting altitude. In normal fashion, the F/O extended the wing spoilers for that purpose. Company policy required him to keep his hands on the Spoiler handle (His left hand) while the spoilers were deployed, as a preventative to using that same hand to increase engine power without first retracting the spoilers. The investigators determined that while the F/O was reaching across the Thrust-levers as he held the Spoiler-lever, he inadvertently pressed the Go-Around button on the left Thrust-lever. That caused to auto-flight system to power-up and pitch-up the aircraft, which was certainly an unexpected event for him to cope with.

Ordinarily, when the auto-flight system goes wonky and does the unexpected, the savy pilot will quickly hit the Master-disconnect and revert to the old fashioned stick, rudder, and power method of flying , and thus maintain control. Unfortunately, in the case of our poor overwhelmed F/O, he didn’t know how. Really. He had been trained so thoroughly automation dependent, and afforded virtually no opportunity to hand fly his airplane, that he simply was unable to fly straight and level, even though he was in the clear and not in a cloud.

Flying a complex aircraft by hand while using flight instruments to determine acceptable and desired flight perimeters is a specific skill which requires practiced hand-eye coordination. It requires a specific eye muscle memory which the industry calls the “instrument scan”. The instrument scan is a skill involving watching several instrument indications in quick succession, so quickly in fact that it is almost simultaneous, while processing that information within one’s head, and applying the correct inputs to the flight controls and power, resulting in the preferred flight condition.

The instrument scan is a very different, and more complex scan than the scan universally used today as our pilots simply follow the Flight-director, as commanded by the Auto-flight system. The Flight-director reduces the scan from several instrument sources to one, which is within the Attitude Indicator., which is it’s raison d’etre (reason to be). In other words, the Flight-director is specifically designed to reduce the complexity of the instrument scan, thus reducing the pilot’s efforts in determining what control inputs are required. Reducing those efforts over time results in loss of the scanning skill. What happens when such a poor, hapless pilot is thrust into the situation of needing a proficient instrument scan, while lacking the skill, is a fixation. He stares at one instrument in a near panic, searching for information, which is elsewhere, and fails to properly control the aircraft. Perversely, his best friend, the Flight-director, was lying to him in this case. The Go-around button told the Flight-director to pitch the aircraft up, which he knew was wrong, thus he simply did not know where go for the pitch information he so desperately needed. Thus it was that in frozen confusion, he simply grabbed the stick and drove the airplane into the water because, for the life of him, he didn’t know what else to do.

I do not know why the captain sat there and allowed that event to happen. Maybe he was just as confused. The NTSB, in their conclusion, made a statement about “...flight crew training issues at Atlas Air and across the US commercial aviation industry.”, and I was involved in some special simulator training maneuvers in the following year involving wing stalls, slow flight, and aircraft controllablilty. I was still dismayed in that while those new training modules were designed to combat the loss of control accidents which we have been lately seeing, I still believe that the underlying cause is being ignored. Pilots must practice basic aircraft control while using the basic instrument scan, which requires them to turn off the automation and simply fly their airplanes.

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