Pilot error and the Federal Aviation Administration’s failure to create a central database to prevent companies from hiring pilots with bad track records are to blame for the Atlas Air plane crash that killed three in 2019, federal investigators have found.
The database, first called for by Congress more than a decade ago, might have prevented Atlas Air from hiring the first officer who was flying at the time of the Feb. 23, 2019, crash near Houston after he had failed training programs at other airlines. Members of the National Transportation Safety Board criticized the FAA Tuesday while discussing the findings of the 17-month investigation by the agency.
“This should be a wake-up call to the industry,” said board member Michael Graham. “An operation is only as good as its weakest player.“
Atlas Air is Miami’s largest cargo airline. In a statement CEO John Dietrich said that since the crash the company has “made several important enhancements to our own hiring, training, and pilot review procedures.”
“Of critical importance is the need for an improved federal pilot records database to provide airlines with full visibility of pilot history in the hiring process,” he said.
On Feb. 23, 2019, Atlas Air flight 3591 left Miami International Airport headed for Houston carrying Amazon packages. Forty miles from Houston at around 12:40 p.m., the Boeing 767 plane pushed to full thrust — the same thrust used during takeoff — and nose dived 6,000 feet down into Trinity Bay. Three people died: 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.
Aska, who was flying at the time, joined Atlas in 2017 after failing a captain’s promotion at Mesa Air and after he had previously dropped out of training programs at Air Wisconsin in 2012 and CommutAir in 2011. Hiring airlines are required to do a background check, but Aska did not mention his employment history at Air Wisconsin or CommutAir to Atlas, so the company did not know to request his records. Atlas delegated the review of prior employment records to a human resources employee without aviation experience who did not notice the failure at Mesa, investigators said Tuesday.
About 30 seconds before the crash, the plane’s go-around switches (used to abandon a landing) were accidentally activated, and the plane suddenly increased in power and pitched upward. Aska mistakenly thought the plane was stalling and dangerously pushed the nose down. Blakely failed to intervene, investigators found.
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 Aska said, “Lord, you have my soul,” right before the crash.
In March, the FAA proposed rules to establish a new database. In a statement, a spokesperson for the FAA said the final rule will be posted January 2021. NTSB Chairman Robert Sumwalt estimated it would take until 2023 for the database to be operational.
“The FAA, if they would have done their job, this pilot would not have been employed by Atlas Air, and therefore this crash would not have happened,” said Sumwalt.
Not far enough
The NTSB made six recommendations Tuesday based on its investigation of the crash. Three related to the pilot records database. The board called for Boeing 767 pilots to be notified about the go-around switch risk, more “scientifically-based pilot selection strategies,” a panel to study automatic ground collision prevention systems used by the Department of Defense, and reiterated a prior recommendation that airlines install image recording systems in cockpits.
Former FAA inspectors and current Atlas pilots say the NTSB investigation and recommendations did not go far enough. While the board determined that the first officer should not have been allowed in the cockpit, it stopped short of recommending any changes to training or safety culture at the airline, which inspectors and pilots say are desperately needed.
The pilots’ record database “will certainly help airlines do their due diligence on prospective pilots, and cameras on the flight decks will certainly help the NTSB do their jobs,” said Michael Russo, a captain who has been at Atlas since 2004. “But I really didn’t see the same level of attention given to Atlas Air and how they managed the biggest and fastest expansion in their entire history.”
NTSB investigators did not interview former FAA inspectors who raised concerns about safety at Atlas Air during their tenures overseeing the airline, including the aircrew program manager directly responsible for the Atlas 767 training and Paul Dolza, who served as an FAA principal operations inspector for Atlas until 2018.
“As extensively documented as my concerns were, I was expecting to be interviewed, and I was surprised that I was not,” Dolza said.
Former FAA inspector David Lithgow, who oversaw Atlas 747 training for 17 years before retiring in 2018, said he believes the NTSB failed to get to the root cause of this accident.
“Frankly I was disappointed that the NTSB failed to drill down to the root cause of this accident which, in my view, was the failure of Atlas Air and the FAA to identify and correct systemic problems in the training and checking of their pilots,” he said. “That failure led to the release of this first officer to conduct line flights.”
Atlas has experienced exponential growth over the past six years, fueled by contracts with Amazon and the U.S. military. 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.
At the same time, former FAA inspectors and current pilots say company training standards and federal oversight dwindled.
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 2016, Atlas changed its one-strike rule for its pilot watch program — designed to provide training support to pilots who need it — to allow for more than one failure, investigators said.
On Sept. 22, 2017, Aska failed his type rating examination for the 767. He was not placed in the watch program as he would have been in early 2016. He passed the exam four days later.
A Miami Herald investigation found that for years before the crash, pilots had been warning Atlas executives about “an erosion of level of experience in the cockpit,” in the words of a veteran captain who raised the concern at a 2017 company meeting in Miami with former CEO William Flynn and current CEO Dietrich, according to a recording of the meeting obtained by the Herald.
Flynn left the company in July 2019 and became CEO of Amtrak in March. Fleet captain Joe Diedrich and training director Scott Anderson, two top directors of the company’s training program in Miami, left earlier this year.
Sumwalt, the NTSB chairman, said a review of Atlas’ training program was outside the board’s purview.
“We really did not do a deep dive into the training at Atlas Air,” he said. “We looked at training as it related to this particular first officer. The inspector indicated that the training was very good. I’m not at a position to say whether the 767 program was deficient.”
“You can train anybody with enough practice to pass,” he added. “That’s apparently what happened here.”
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