NTSB CAROL · Event
Event DCA19MA086
Registry · N1217A
FAA Aircraft Registry record.
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
Registrant of record
ANDROMEDA LEASING I LLC
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
Hierarchical cause / factor breakdown from the FAA bulk avdata database. Each finding tagged C (Cause) or 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
What the literature says.
Academic papers and agency reports matching this event's aircraft type or causal vocabulary (spatial disorientation, go-around). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.
- NTSB Aircraft Accident Reports 2021 · Accident report
Crash of Atlas Air Flight 3591, Boeing 767-300 (N1217A)
Atlas Air 3591 crashed into Trinity Bay, Texas, February 23, 2019. Investigation of the in-flight loss-of-control crash of Atlas Air 3591 into Trinity Bay, Texas.
- NTSB Aircraft Accident Reports 2018 · Accident report
Atlas Air Flight 3591 Boeing 767 Loss of Control (preliminary)
Atlas Air 3591 / Boeing 767-300 / Trinity Bay TX (Feb 23 2019) — preliminary. Preliminary investigation findings; superseded by the AAR-21/01 final report.
- NASA NTRS 2025 · Conference Paper
A Training Study to Improve Monitoring During A Go-Around
As part of an FAA program to improve go-around (GA) safety, we were asked to determine if we could improve the performance of the Pilot Monitoring (PM) during a GA maneuver.
- Embry-Riddle Scholarly Commons 2025 · Journal article (IJAAA)
Design, Implementation, and Testing of Spatial Disorientation Scenarios in a Modified Hexapod Motion Simulator
Abstract Investigations into aviation accidents aim to identify root causes and enhance safety. Despite advancements in safety measures, technology, and education, general aviation accident rates rema…
- Flight Safety Foundation 2024 · FSF / AeroSafety World
Go-Around Safety Forum Findings
Foundation Go-Around Safety Forum technical findings — examines why pilots fail to execute go-arounds when criteria are met (stabilized approach gate not met, energy state out of envelope, traffic con…
- AOPA Air Safety Institute 2022 · Safety advisor
Safety Advisor: Spatial Disorientation
Safety advisor on the perceptual illusions that cause spatial disorientation: the leans, graveyard spiral, somatogravic and somatogyral illusions, false horizon, and Coriolis.
Browse the full corpus — academia portal ↗