Prime Air Boeing 767-300F N1217A operated by Atlas Air Inc. Photo: Nathan Coats

MIAMI – On July 14, 2020, the National Transportation Safety Board (NTSB) held its public board meeting on the Atlas Air (5Y) 3591 Investigation.

During descent into Houston’s George Bush Intercontinental Airport (IAH), the go-around mode was inadvertently activated. The flight was descending through 6300 feet, and neither pilot made a call out to indicate that the activation was intentional.

Within seconds of the go-around activation, manual inputs into the flight systems overrode the autopilot, and the aircraft went into a steep dive. Within 32 seconds from activation of the go-around, the aircraft impacted the ground.

The FO, who was the Pilot Flying, experienced a pitch-up somatogravic illusion during the acceleration from the change in mode. This meant that he believed that the aircraft was stalling, even though it was not.

The Captain was unable to recover the aircraft due to the short time frame and lack of flight path monitoring.

Boeing 747 47UF(SCD), Atlas Air JP6920403. Photo: Atlas Air

System Safety Issues

While the inadvertent activation of the go-around mode was a cause of the accident, the NTSB believes that it is a “rare and usually benign event”. However, they also state that pilots should be made aware of the circumstances related to this accident.

The NTSB also states that the addition of automatic ground collision avoidance technology might be a way forward in tackling accidents of these types. The military uses the technology for fighter aircraft, so it would need to be adapted for commercial use.

As it has been more common in recent investigations, the NTSB also calls for Cockpit Image Recorders. These are a contentious topic for pilots and pilot unions, as there would be a direct lack of privacy within the cockpit. Therefore it is highly unlikely that these will be added.

This modified 747-400 is one of four samples operated by Atlas Air for transporting 787 Dreamliner parts to Boeing’s assembly plants. PHOTO: BOEING.

Aviation Industry Safety Issues

The NTSB highlights issues with Pilot Record Tracking within the USA. Both the Capt. and FO had the required certifications and qualifications.

The Board states that the FO did not highlight some training difficulties in the past at a different employer. Even though Atlas Air conducted their own record review, they also did not find out this information.

The FO had a long history of training performance difficulties, including responding impulsively and inappropriately when faced with unexpected events in training. This information was deliberately hidden from future employers through incomplete and inaccurate information.

Atlas Air used designated agents to review Pilot backgrounds, which the NTSB declared as “inappropriate and resulted in the company’s failure to evaluate the first officer’s unsuccessful attempt to upgrade to captain at his previous employer”.

The NTSB also states that subject matter experts should be introduced early in the review process.

This SonAir VIP Boeing 747-400 is operated by Atlas Air in a business class cabin configuration. PHOTO: Atlas Air.

Pilot Records Database

After the Colgan Air accident in 2009, Congress mandated that the FAA create a centralized database for part 119 certificate holders. The Proposed Rule from the Federal Aviation Administration (FAA) was put out on March 30, 2020.

Several organizations, such as the AOPA and the NBAA have voiced concerns in how the database is being implemented. Some concerns are related to privacy, undue burden on individual pilots, and does not accept industry recommendations.

The NTSB has directly stated that the FAA’s failure to implement the system in a robust and timely manner is a direct contribution to the Atlas Air accident. The implementation of the database would have prevented any deliberate hiding of training information, and might have prevented this accident.

The NTSB also reiterates 4 safety recommendations to the FAA, all related to pilot training a certification, and all classified as “Open – Unacceptable Response”. The recommendations all are related to having clear and understandable tracking of pilot records, especially when pilots change employers.

While this accident was a cargo aircraft, the safety issues highlighted here affect US aviation as a whole. Having the system be manual allows for hiring operators to not obtain the full background of an applicant. NTSB Member Jennifer Homendy stated well, that “This could happen to anyone”.