An accidental button press set off the fatal dive of Atlas Air Flight 3591
About 29 seconds after the flaps began moving on its approach to Houston, something switched the cargo jet's go-around mode on by accident, and the engines surged toward climb power. Investigators concluded the first officer, disoriented in cloud, answered by pushing the nose down, and the Boeing 767 hit Trinity Bay 31 seconds after the mode engaged.
The flight, run by Atlas Air for Amazon Air between Miami and Houston, came down on February 23, 2019 near Anahuac, Texas, killing both pilots and a pilot from another airline riding in the jumpseat. It was the first fatal crash of a 767 freighter and the first involving Amazon Air. The airframe, built in 1992, had flown passengers for China Southern and LAN before becoming a freighter in 2017, and Amazon had painted it with the pun name CustomAir Obsession.
Weather played a part. The jet was crossing the leading edge of a cold front, flying through cloud and turbulence with no outside horizon, when the controller had asked it to hurry its descent and steer west of the storms. In those conditions a sudden push of acceleration can feel like the nose pitching up. Data showed the aircraft pitching down to about 49° over 18 seconds in response to elevator movement.
The NTSB's final report, posted on August 6, 2020, blamed the first officer's inappropriate response to the unintended go-around activation, and faulted the captain for not monitoring the flight path and taking control. It went further, citing an industry whose pilot selection and assessment had missed the first officer's long record of performance problems at four earlier airlines, and the FAA's slow rollout of a pilot records database that might have flagged them.
The investigation was vast: a public docket released on December 19, 2019 ran to more than 3,000 pages, covering human performance, air traffic control and a full voice recorder transcript. Recovery crews needed airboats because the crash site was mud marsh under no more than five feet of water.
Source: Atlas Air Flight 3591
