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DCA19MA086

2019-02-23 · Trinity Bay, Texas, United States · Fatal · 1 aircraft · Status: Completed

Airport KIAH

Current FAA registration · N1217A

Make / Model
BOEING 767-375
Year of manufacture
1992 · 27 years old at event
Engine
GE CF6-80C2B6F
Seats / Engines
330 seats · 2 engines
Last airworthiness date
20170406
ADS-B equipped
Yes — Mode-S A05AB7

Source: FAA Aircraft Registry (releasable master file).

Aircraft involved

Probable cause & findings

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 flightpath 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.

Factual narrative

The Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/aviation.aspx. The Aircraft Accident Report number is NTSB/AAR-20/02. On February 23, 2019, at 1239 central standard time, Atlas Air Inc. flight 3591, a Boeing 767-375BCF, N1217A, was destroyed after it rapidly descended from an altitude of about 6,000 ft mean sea level and crashed into a shallow, muddy marsh area of Trinity Bay, Texas, about 41 miles east-southeast of George Bush Intercontinental/Houston Airport (IAH), Houston, Texas. The captain, first officer, and a nonrevenue pilot riding in the jumpseat died. Atlas operated the airplane as a Title 14 Code of Federal Regulations Part 121 domestic cargo flight for Amazon.com Services LLC, and an instrument flight rules flight plan was filed. The flight departed from Miami International Airport, Miami, Florida, about 1033 (1133 eastern standard time) and was destined for IAH. The Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/aviation.aspx. The Aircraft Accident Report number is NTSB/AAR-20/02.  On February 23, 2019, at 1239 central standard time, Atlas Air Inc. flight 3591, a Boeing 767-375BCF, N1217A, was destroyed after it rapidly descended from an altitude of about 6,000 ft mean sea level and crashed into a shallow, muddy marsh area of Trinity Bay, Texas, about 41 miles east-southeast of George Bush Intercontinental/Houston Airport (IAH), Houston, Texas. The captain, first officer, and a nonrevenue pilot riding in the jumpseat died. Atlas operated the airplane as a Title 14 Code of Federal Regulations Part 121 domestic cargo flight for Amazon.com Services LLC, and an instrument flight rules flight plan was filed. The flight departed from Miami International Airport, Miami, Florida, about 1033 (1133 eastern standard time) and was destined for IAH. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12

NTSB Findings

FAA avdata. C = Cause, F = Factor.

  • F Organizational issues-Support/oversight/monitoring-Documentation/record keeping-Personnel records-Not specified
  • F Organizational issues-Support/oversight/monitoring-Documentation/record keeping-Personnel records-FAA/Regulator
  • — Aircraft-Aircraft systems-Auto flight system-(general)-Unintentional use/operation
  • — Personnel issues-Experience/knowledge-Experience/qualifications-Qualification/certification-Copilot
  • — Personnel issues-Psychological-Perception/orientation/illusion-(general)-Copilot
  • — Personnel issues-Experience/knowledge-(general)-(general)-Copilot
  • — Personnel issues-Psychological-Attention/monitoring-Attention-Pilot
  • — Personnel issues-Psychological-Personality/attitude-Personality-Copilot
  • — Personnel issues-Task performance-Use of equip/info-Use of automation-Copilot
  • — Personnel issues-Action/decision-Action-Incorrect action performance-Copilot
  • — Aircraft-Aircraft systems-Indicating/recording systems-Data recorders (flight/maint)-Design
  • — Aircraft-Aircraft systems-Auto flight system-(general)-Design

Verbatim from NTSB's published report. Source file NTSB_2019_DCA19MA086.txt. Findings + structured fields enriched from FAA avall.mdb. Full investigation docket on data.ntsb.gov ↗.

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Related research

Matched on aircraft type or causal vocabulary (spatial disorientation, go-around). All research papers