Atlas Air Flight 3591


Atlas Air Flight 3591 was a scheduled domestic cargo flight operating for Amazon Air between Miami International Airport and George Bush Intercontinental Airport in Houston. On February 23, 2019, the Boeing 767-375ER used for this flight crashed into Trinity Bay during approach into Houston, killing the two crew members and one passenger on board. The accident occurred near Anahuac, Texas, east of Houston, shortly before 12:45 CST. Debris was found in the shallow waters of Trinity Bay, ranging from small articles of clothing to large aircraft parts. This was the first fatal crash of a Boeing 767 freighter.

Accident

3591 was on approach towards Houston when it made a sharp turn south before going into a rapid descent. Witnesses to the crash described the plane entering a nosedive; some also recalled hearing "what sounded like lightning" before the Boeing 767 hit the ground.
At 12:36 CST radar and radio contact was lost. There was no distress call. Shortly before 12:45 CST, Flight 3591 crashed into the north end of Trinity Bay at Jack's Pocket. The area of water is within Chambers County, Texas, and is in proximity to Anahuac.
The Federal Aviation Administration issued an alert after radar and radio contact was lost around southeast of its destination. Air traffic controllers tried at least twice to contact the flight, with no response. Controllers asked pilots aboard two nearby flights if they saw a crash site, both of whom said they did not.
The United States Coast Guard dispatched a helicopter and several boats to search for survivors. Numerous other agencies responded as well. The largest piece of aircraft debris found was less than in length. Some of the debris had the Amazon logo visible. The accident site was only accessible via airboat and helicopter.
The water varies in depth from zero to deep and is partially mud marsh.

Aircraft

The Boeing 767-375ER aircraft was registered N1217A and was nearly 27 years old at the time of the accident, having been built in 1992. It was originally ordered by Canadian Airlines, but first placed into service by China Southern Airlines through GPA, an aircraft leasing company. In 1997, it was transferred to LAN Airlines and flew for 19 years before being stored in January 2016. It was converted into a freighter in April 2017, and placed into service for Amazon Prime Air by Atlas Air. In August 2018, Amazon named two aircraft in its fleet, including N1217A as CustomAir Obsession. The name, painted on the aircraft just aft of the cockpit windows, was a near homonym of "customer obsession," an Amazon leadership principle. The aircraft had accumulated more than 91,000 hours over 23,300 flights and was powered by two GE CF6-80 turbofan engines.

Victims

There were three people onboard the aircraft. On February 24, Atlas Air confirmed that all three died.
Captain Ricky Blakely of Indiana, First Officer Conrad Jules Aska of Antigua, and Mesa Airlines Captain Sean Archuleta of Houston were first identified as the three victims on social media by friends and family. Sean Archuleta was in his final week of employment at Mesa Airlines, and was traveling home before beginning new-hire pilot training with United Airlines, scheduled for the following week. By February 26 the bodies of all three had been recovered, and by March 4 all had been positively identified.
Captain Blakely had logged a total of 11,172 flight hours, including 1,252 hours on the Boeing 767. First officer Aska had logged 5,073 flight hours with 520 of them on the Boeing 767.

Investigation

Investigators from the FAA, Federal Bureau of Investigation, and National Transportation Safety Board were dispatched to the accident site with the NTSB leading the accident investigation. A dive team from the Texas Department of Public Safety was tasked with locating the aircraft's flight recorders and dive teams from the Houston and Baytown police departments were also on-scene assisting in the search. The cockpit voice recorder and flight data recorder were located and transported to an NTSB lab for analysis. It was thought that crews would likely remain at the accident site for weeks for recovery.
As of March 2019, the cause of the accident had not been determined. It was noted that storm cells were nearby at the time of the accident, but this is not unusual for Bush Intercontinental. CCTV cameras at the Chambers County jail show the airplane in a steep, nose-low descent just prior to impact.
The FAA, Boeing, Atlas Air, National Air Traffic Controllers Association, International Brotherhood of Teamsters, Air Line Pilots Association, and engine maker General Electric assisted or offered their assistance to the NTSB inquiry.
After listening to the cockpit voice recorder the NTSB stated that "Crew communications consistent with a loss of control of the aircraft began approximately 18 seconds prior to the end of the recording." On March 12 the NTSB stated that the airplane "pitched nose down over the next 18 seconds to about 49° in response to column input." Later that same day the statement was changed to "...in response to nose-down elevator deflection."
On December 19, 2019, the NTSB released a public docket containing over 3,000 pages of factual information it had collected during the investigation, with a final report to follow at an unspecified later date. The docket contains information on "operations, survival factors, human performance, air traffic control, aircraft performance, and includes the cockpit voice recorder transcript, sound spectrum study, and the flight data recorder information."
On June 11, 2020, the NTSB announced that the next board meeting would determine the cause of the accident;
the NTSB determined during a public board meeting held on July 14, that the flight crashed because of the first officer’s inappropriate response to an inadvertent activation of the airplane’s go-around mode, resulting in his spatial disorientation that led him to place the airplane in a steep descent from which the crew did not recover. The NTSB released an animation of the mishap sequence of events from the selection of Go-Around thrust to the fatal crash 31 seconds later.

Lawsuits

On May 20, 2019, the estate of Captain Sean Archuleta filed a suit against Amazon and Atlas Air in federal court. The suit accuses the defendants of failing to operate the aircraft in a safe manner.
On September 9, 2019, the family of first officer Conrad Jules Aska filed a wrongful death lawsuit against Amazon and Atlas Air, citing improper training and negligence.