In the span of 30 seconds, a Boeing 767 flight that left Miami International Airport in February full of Amazon packages went from a normal flight to out of control.
Panic and confusion filled the cockpit of doomed Atlas Air Flight 3591 in its final moments before crashing into the ground 40 miles outside of Houston on February 23, 2019, new government documents show. The crash killed three people: captain Ricky Blakely, 60, of Indiana; first officer Conrad Jules Aska, 44, of Miami; and Mesa Air pilot Sean Archuleta, 36, of Texas, who was riding as a passenger on the flight.
Documents released by the National Transportation Safety Board on Thursday as part of its investigation into the crash show that the go-around switches were activated 30 seconds before the crash, and the plane suddenly increased in power and pitched upward. Aska mistakenly thought the plane was stalling, and overpowered the autopilot, dangerously pushing the nose down.
The documents also show that Atlas hired Aska despite his training failures at other airlines, and paired him with Blakely, who had had training difficulties at Atlas.
The NTSB report does not include the agency’s conclusion about the cause of the crash. That final assessment is expected in the next six months, an agency spokesperson said.
Aska came to Atlas in 2017 after failing his test to become a captain at Mesa Air. He had previously dropped out of training programs at Air Wisconsin in 2012 and CommutAir in 2011, but did not list those employment stints on his application with Atlas.
Atlas director of training Scott Anderson told investigators, “If I had that information at the time we would not have offered him a position.” The failure to win a promotion to captain at Mesa was not treated as a red flag in the Atlas hiring process.
In 2015, Blakely failed his proficiency test on the Boeing 767 and was placed in a monitoring program “as a result of [his] repetitive need for additional training.” Blakely was removed from the monitoring program in February 2017.
A June Miami Herald investigation found that pilots for Atlas Air, MIA’s largest cargo airline, warned company executives in the years leading up to the February crash that if they did not beef up the training program and hire pilots with more experience, they were going to crash a plane. At a meeting with executives in Miami in 2017, a pilot who had been with the company for two decades described an “erosion of level of experience in the cockpit.”
As Aska and Blakely approached Houston, the cockpit recorder picked up a clicking noise and the autoflight system entered “go-around mode,” meant for when a landing is called off and a plane has to circle and try to land again. The plane began to pitch up and increase in power 30 seconds before it crashed into the ground.
Seventeen seconds later, Aska said, “We’re stalling,” and then “Oh, Lord have mercy myself.”
Seven seconds later, Blakely said, “What’s going on?”
Someone shouted, “Oh, God.”
Then Aksa said, “Lord, you have my soul.”
The plane was not stalling, a condition associated with slowed speed. To recover from the perceived stall, Aska pushed the nose down. Blakely intervened and pulled the nose up, but it was too late. The plane nose dived 6,000 feet into Trinity Bay at nearly 500 miles per hour.
Shem Malmquist, a Boeing 777 captain at a different cargo airline and professor of advanced aircraft operations at the Florida Institute of Technology’s College of Aeronautics, said based on this preliminary report it looks like the go-around switch was activated inadvertently, and it is possible that the first officer became disoriented.
A spokesperson for Atlas Air said the company is cooperating with the NTSB to get to the cause of the crash.
“We remain devastated by the loss of Flight 3591 that claimed the lives of two of our valued pilots and a colleague,” the spokesperson said in a statement. “We continue to provide their families with care and support. The safety of our employees is always our top priority. Atlas’ workforce and fleet meet or exceed all government safety standards. Atlas pilot training includes multiple reviews, evaluations and proficiency checks to comply with FAA regulations. We continually evaluate all training and hiring procedures, and in addition, in the aftermath of Flight 3591, we enhanced training for our employees and expanded background checks for all candidates.”
Outcry from Atlas pilots about lack of experience has come at a time of exponential growth for the company, fueled by the online shopping boom and U.S. military contracts. Since 2014, Atlas grew its fleet by 90% from 60 planes to 114, including 51 Boeing 747s, making it the world’s largest 747 carrier. In 2016, Atlas agreed to dedicate 20 of its planes to Amazon shipments by the end of 2018 and give Amazon the right to acquire 30% of the company’s common shares. Earlier this year Amazon increased its stake in Atlas by acquiring another five Atlas planes and upping its rights to reach 40% of common shares.
In its report, the NTSB found that total average flying time for new hires at Atlas and its subsidiary, Southern Air, dropped to around 5,600 hours in 2018, compared to 7,303 hours in 2015. Two-thirds of pilots have been with the company for less than five years. The FAA requires that new hires have 1,500 hours.
In May, the widow of Archuleta, the pilot who was a passenger on the fatal flight in February, sued Atlas Air and Amazon in federal court, alleging the companies failed to adequately train their pilots and prevent the crash. That case is still pending.
Aska’s brother, Elliott Aska, filed a wrongful death lawsuit against Atlas and Amazon in September in Miami-Dade County court claiming that the company failed to properly train its pilots, to prevent pilot fatigue, and to respond to prior incidents involving its aircraft. That case is still pending.
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