Atlas Air Flight 3591 was a scheduled domestic cargo flight between Miami International Airport and George Bush Intercontinental Airport in Houston, operated by Atlas Air on behalf of Amazon Air. On February 23, 2019, the Boeing 767 operating this flight crashed into Trinity Bay during approach into Houston, killing the two crew members and single passenger on board. The accident occurred near Anahuac, Texas, east of Houston, shortly before 12:45 CST (18:45 UTC). This was the first fatal crash of a Boeing 767 freighter, and the first fatal crash involving Amazon Air.
Investigators attributed the accident to pilot error, finding that the first officer – who had years of flight performance issues at four previous airlines – experienced spatial disorientation and inadvertently placed the aircraft in an unrecoverable dive, while the captain failed to adequately monitor the first officer's actions and the flight path of the aircraft. Flight crew training issues at Atlas Air and across the U.S. commercial aviation industry were also implicated.
The Boeing 767-375ER(BCF) (MSN 25865/430) 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 it was first placed into service by China Southern Airlines through GPA, an aircraft leasing company. In 1997, the aircraft was transferred to LAN Airlines and flew until 2014 before being returned to lessor CIT, which then stored it in January 2016. In April 2017, the 767 was converted into a freighter and placed into service for Amazon 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 across 23,300 flights and was powered by two GE CF6-80 turbofan engines.
There were three people on board the aircraft: Captain Ricky Blakely of Indiana (60), First Officer Conrad Jules Aska of Cedar Grove, Antigua (44), and Mesa Airlines captain Sean Archuleta of Houston (36; a jumpseater aboard the flight), who was in his final week of employment at Mesa Airlines and was traveling to work before beginning new-hire pilot training with United Airlines scheduled for the following week.
Blakely joined Atlas Air in 2015 and became a Boeing 767 captain in 2018. Before being hired by Atlas Air, Blakely had previously been an Embraer ERJ-145 captain for ExpressJet. He had also been a Beechcraft 1900 first officer for CommutAir, and a flight instructor for FlightSafety International. Blakely logged a total of 11,172 flight hours, including 1,252 hours on the Boeing 767.
Aska joined Atlas Air on July 3, 2017, and received his type rating on the Boeing 767 two months later. He had logged 5,073 flight hours, with 520 of them on the 767. Aska had previously been an Embraer E175 first officer with Mesa Airlines (and served with five other airlines prior to that) and also had experience on Embraer's EMB 120 Brasilia and ERJ aircraft families.
Both pilots had previous experience in landing at George Bush Intercontinental Airport and they flew together on the previous day, operating a night-time flight from California to Miami.
Atlas Air 3591 departed Miami at 10:33 CST (11:33 EST), with First Officer Aska as pilot flying and Captain Blakely pilot monitoring. At 12:36, Aska transferred control of the aircraft to Blakely, telling him that the electronic flight instrument (EFI) switch on his side had malfunctioned. This issue was resolved a minute later, with the following being recorded on the cockpit voice recorder (CVR):
Aska: "I press the E-fy button, it fixes everything."
Flight 3591 was on approach towards Houston when it flew through the forward edge of a cold front, which produced an area of instrument meteorological conditions (IMC) with clouds and turbulence, with cloud tops varying from approximately 19,500 feet (5,900 m) to 27,300 feet (8,300 m) of altitude and cloud bases varying from 2,000 feet (610 m) to 3,000 feet (910 m) above ground level. The pilot of another nearby airliner reported IMC, and a video taken by a ground witness showed a shelf cloud passing over the area at the time.
Aska then requested radar vectors to the west side of the airport to avoid the inclement weather. The controller accepted but also advised the crew to expedite their descent to 3,000 feet (910 m) and said, "I'm gunna get ya west of this weather and northbound for a base leg." Blakely then transferred control of the aircraft back to Aska:
The flight crew then started to configure the aircraft for landing and set up the flight management system (FMS). At 12:38:02.2 CST, Aska called out "flaps one”, and the slats were extended. 29 seconds later, the aircraft's go-around mode was inadvertently activated. At 12:38:40.3, the following was heard on the CVR:
Cockpit area microphone (CAM): [Sound of master caution aural warning]
Blakely (radio transmission): "Sounds good uh Giant thirty-five ninety-one."
Approach controller: "It is severe clear on the other side of this stuff so you'll have no problem gettin' the airport [unintelligible word] (either)."
Aska: "Oh. Woah! (Where's) my speed my speed? [Spoken in elevated voice]
CAM: [Sound similar to a mechanical click]
Blakely (radio transmission): "Okay."