- vor 2 Tagen
On 23 February 2019, Atlas Air Flight 3591 crashes into Trinity Bay while on final approach to George Bush Intercontinental Airport in Houston, Texas, killing all 3 people on board. The first officer suffered spatial disorientation after inadvertently activating the aircraft's go-around mode.
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00:00Want to go east?
00:03We'll go on the west side.
00:05A flight carrying cargo for the online retailer Amazon falls from the sky.
00:11What's going on?
00:14I thought I'd pursue upon myself.
00:17It crashes into a swamp 40 miles outside Houston, Texas.
00:21There are no survivors.
00:23We literally had to shuffle along with our feet and hands in this water and mud in order to find anything.
00:30As investigators attempt to piece together the wreckage, security footage gives them a valuable lead.
00:38767s just don't fly straight down like that.
00:41Could the sudden loss of altitude have been deliberate?
00:45It's possible.
00:46Lord of mercy!
00:48Come on!
00:483, 3, 4!
00:51Maybe, maybe, maybe!
00:55Oh, fuck!
00:563, 2, 3, 1, 0, 3, 2, 0.
00:592, 0, 3, 0, 3, 0, 3, 0.
01:012, 0, 4, 3, 0.
01:01That's their own project.
01:061, 2, 0.
01:0737-year-old first officer Conrad Asker has been a professional pilot for four years.
01:21He's at the controls of tonight's flight, cruising at 35,000 feet.
01:28There's a sudden decompression of the cabin.
01:32Asker must descend immediately to 10,000 feet where there is breathable oxygen.
01:37The number of warnings proves overwhelming.
01:45Wait, wait, wait a second.
01:49This is day four of training on this type of aircraft.
01:54He really had trouble managing difficult situations.
01:59When you threw something at him, he would be more likely to panic rather than troubleshoot.
02:05OK, Conrad, I'm going to reset to 35,000. Let's try this again.
02:13Two years later, while working for Trans States Airlines,
02:17first officer Asker fails a check ride, an oral exam, and a line check on the Embraer jet.
02:23He did react very severely to minor disturbances, basic stuff, pilot 101, instrument type of errors.
02:34Three years later, after failing captain training at Mesa Airlines, Asker's career is now in jeopardy.
02:47Atlas Flight 3591 cruises over the Gulf of Mexico.
03:06Speed 250.
03:0760-year-old captain Ricky Blakely has been a pilot for 17 years.
03:13He is monitoring today's flight to Houston, Texas.
03:176,000 is our bottom altitude.
03:20First officer Conrad Asker is at the controls.
03:25There's a third off-duty pilot on board hitching a ride.
03:29Roger, 6,000.
03:30The pilots are flying a Boeing 767-375.
03:36It's what they call a BCF, a Boeing-converted freighter.
03:40It used to be in passenger service, and then they removed all the seats,
03:44cut a new cargo door, and then it entered service as a freighter.
03:48The 767 serves a lot of markets very well.
03:51The Boeing 767 is a reliable, automated, wide-bodied plane
03:57that has a load capacity of 52 tons for Atlas Air.
04:03Atlas Air is a cargo and passenger airline that flies for various contractors,
04:11but their biggest customer is Amazon.
04:15Atlas 3591 took off from Miami with 26,000 pounds of cargo.
04:21It's a two-and-a-half-hour flight to Houston.
04:25All right. Confirmed.
04:29279 miles from their destination, the pilots set a target altitude for descent.
04:37Attention all aircraft.
04:39Hazardous information, Houston center.
04:42There's a weather advisory.
04:43It's going to be a bit choppy coming in.
04:46Giant 3591. Copy that.
04:48For today's flight, Atlas Air's call sign is Giant 3591.
04:55Oh. Could be a bumpy ride.
05:00You say something?
05:01Uh, no.
05:02Okay. As far as my technique to land this plane...
05:08It's hard to hear you, man.
05:10Oh, okay.
05:12As far as my technique to land this plane at a thousand feet,
05:14I'll take autopilot off.
05:16Okay.
05:17It's a good plan.
05:18Twenty-one miles from the airport, the 767 continues its descent towards Houston.
05:29Giant 3591, Houston center.
05:32There's a light to heavy precipitation west of Dayton moving eastbound.
05:37A few minutes later, the controller updates the crew.
05:41There was a cold front that was moving from the northwest to the southeast that they would have to navigate around.
05:47This was just a routine cold front, no convective activity to really worry about.
05:53All right, thanks for the heads up, Giant 3591.
05:58How do you want to get around this stuff? Cut to the east of it and join up on the north side?
06:03One second, I'll get right back with you.
06:05Your controls? Great. My controls.
06:09The first officer hands control to the captain while he considers his route around the precipitation.
06:18Somebody always needs to be flying the airplane.
06:21So the pilot flying, if he needs to do something, will hand off the controls to the pilot monitoring,
06:25and then they switch roles at that point.
06:31Want to go east?
06:34Giant 3591 will go on the west side.
06:40The only problem is there's a bunch of departures in the west.
06:44But if you hustle all the way down to 3,000, I can get you west of this weather.
06:48The crew decided to go west.
06:51Air traffic controls got departures coming out of the airport,
06:54so they did ask them to hurry on down to 3,000 feet.
06:59Captain Blakely sets the new target altitude.
07:033,000. Set.
07:04The autopilot begins to descend earlier to reach the target altitude.
07:12To slow the plane, the first officer deploys the speed brakes.
07:16It actually puts an airfoil up on the wing of the airplane that will slow the airplane down.
07:23It's also very helpful to use to descend the airplane if you need to get down faster than a normal configuration with a clean wing.
07:29As the plane continues towards Houston...
07:33EFI?
07:34...the first officer notices that one of his flight displays has gone blank.
07:39The EFI, or Electronic Flight Instrument System, displays vital flight and performance data.
07:46Okay. I got it back.
07:49Now it's back.
07:51Yeah, press the button. It fixes everything.
07:54If there's some problem with the display in front of you, what you want to do is cycle it.
07:58It'll switch to the center, and then brings it back to your own side of the aircraft.
08:03All right. Your controls.
08:06My controls.
08:08The captain hands control back to First Officer Asker.
08:13Okay.
08:15Flaps one.
08:17Forty miles from the airport, the crew configures the plane for landing.
08:23Every time you approach an airport, it could be different configurations, different runways you're landing on.
08:27So it's always good to get ahead of the airplane and prepare for the approach as soon as you possibly can.
08:32That way you've got a mental picture of what's going on as you enter the terminal area.
08:37It's supposed to be on heading, yeah?
08:40As Flight 3591 gets closer to the airport,
08:43the pilots prepare for their final approach.
08:47Giant 3591 and about another 18 miles.
08:50We'll cut you to north for a base leg.
08:55Real clear on the other side of this weather, so there should be no problem getting to the airport.
08:59The controller informs the crew that he'll direct the plane north after they divert around the weather.
09:05Okay, giant 3591.
09:11Where's my speed?
09:14My speed?
09:15We're stalling.
09:22Stall.
09:25What's going on?
09:27Lord have mercy about myself.
09:28Lord have mercy, Captain!
09:36Pull up!
09:38The pilots of Flight 3591 struggle to recover the plane.
09:43But they're too late.
09:45Atlas Air 3591 has crashed into the marshy waters of Trinity Bay, 40 miles east of Houston.
10:06There are no survivors.
10:0926,000 pounds of cargo has sunk into swamp mud.
10:12A team from the NTSB, the National Transportation Safety Board, wades through the marsh to salvage the wreckage.
10:21We've had deep water, we've had forests and jungles and wide areas,
10:27but this combined pretty much everything to make it one of the most difficult, time-consuming and challenging recoveries
10:33I'd seen in all my years at the board.
10:35While the painstaking recovery effort continues,
10:42NTSB investigator Bill English sets up an operations base in nearby Baytown, Texas.
10:49Take a look at the debris field.
10:53NTSB investigator David Lawrence joins the team.
10:57He has worked on more than 300 air accidents.
11:00Split into a million pieces.
11:04You know what that means.
11:08Looking at the debris field and how disintegrated everything was,
11:12you could tell that this airplane came at a high velocity into the ground.
11:17It was a high energy impact.
11:19Any news on the recorders?
11:22Not yet.
11:22The plane's recorders are key to solving the mystery of Atlas 3591's crash.
11:30But the splintered wreckage won't make them easy to find.
11:35The wreckage was completely or partially submerged in this mud and silt-filled water,
11:41and we literally had to shuffle along with our feet and hands in order to find anything.
11:46We didn't know if we were ever going to recover the flight recorders.
11:49I pulled the data on Atlas 3591 and the transcript of our radio exchange.
11:58While the team waits for the recorders to be recovered,
12:01David Lawrence speaks to the controller who directed the plane towards Houston.
12:07I wanted to hear the pilots and the last conversations they had
12:11and the last control instructions air traffic had with the accident flight.
12:16It's also this.
12:17Looks like it could get bumpy in there.
12:22Did the crew mention lightning or if they were struggling?
12:26Mm-mm.
12:27There was a cold front that was moving through the Houston vicinity,
12:30but nothing that would knock a 767 out of the sky that morning.
12:34What about distressed ankles?
12:36Any communications of that sort?
12:37Nope.
12:38Nothing.
12:39See here?
12:39I gave them the weather info.
12:41They said okay, and I didn't hear from them after that.
12:43There was no mayday call.
12:47Their communications were standard and normal with air traffic control,
12:51so there was no indication that there was a problem with the airplane.
12:55Here's the final few minutes of the plane's track.
12:58See?
12:59Here.
13:00The altitude dropped quickly.
13:03Oh.
13:04Investigators don't know why Atlas 3591 crashed,
13:08but its sudden dive gives them a clue.
13:11Well, thanks.
13:13I'll be in touch if I have more questions.
13:14The airplane, as it was descending towards 6,000 feet,
13:20suddenly began a very steep dive straight down to the ground.
13:32With weather eliminated as a reason for the crash...
13:36Maybe it's a flight control problem.
13:38Investigators turn to the wreckage for clues.
13:41Let's see if we can find the jack screw.
13:43A jack screw inside the tail controls the horizontal stabilizer.
13:51As the jack screw turns,
13:53it moves the stabilizer up and down
13:55to adjust the pitch of the aircraft.
14:02Looks like most of it is here.
14:06Well, it's banged up from the impact,
14:07but there's no evidence of excessive wear,
14:09no stripped threads.
14:10It's 11.25 inches.
14:16Nothing unusual here.
14:19The position of the controls on the jack screw
14:23was consistent with pilot-type control inputs,
14:26not some kind of runaway.
14:27Let's take a look at the plane's descent profile.
14:34With a runaway stabilizer ruled out,
14:37investigators return to the plane's descent.
14:40It's a normal descent until here, about 6,000 feet.
14:45Could the sudden loss of altitude have been deliberate?
14:47The plane's track has the chilling hallmarks of a deliberate act.
14:54It's possible.
14:56In the past, pilots have purposefully crashed the airplane
15:00due to psychological problems.
15:02In 2015, the first officer on a German wing's airbus
15:10locked the captain out of the cockpit,
15:12increased the aircraft's speed,
15:14and deliberately crashed the plane into the French Alps,
15:17killing all 150 people on board.
15:20Two years earlier, a LAM Mozambique flight crashed in Namibia,
15:27killing 33 people,
15:29after the captain altered the autopilot
15:31to fly the plane into the ground.
15:33Both these incidents, the pilots were dealing with some serious issues.
15:44I'll get our crew's medical records.
15:48As the team looks into the mental health of Atlas 3591's crew,
15:53they receive news from the recovery effort.
15:56They found the cockpit voice recorder.
15:58The cockpit voice recorder is sent to Washington, D.C. for processing.
16:07Captain's medical file.
16:12There's no issues here.
16:14He passed his medical checks.
16:16There's no history of depression
16:17or any other major personal issues.
16:22What about the first officer?
16:26He passed all his medical tests.
16:28There was nothing in the medical histories of these pilots
16:31that was a red flag for an intentional act type scenario.
16:38Ah, good timing.
16:40Thanks.
16:43The cockpit voice recording should shed light
16:46on why Atlas 3591 was in a high-speed descent.
16:56Speed, 250.
16:586,000 is at bottom altitude.
17:02Roger, 6,000.
17:05They're discussing target altitude.
17:07Pretty standard stuff.
17:09I don't detect any stress in their voices.
17:11None.
17:13Now, fast forward a little bit.
17:14All right, thanks for the heads up.
17:22Giant 3591.
17:25How do you want to get around this stuff?
17:27Cut to the east of it and join up on the north side?
17:30One second, I'll get right back with you.
17:33Want to go east?
17:34As investigators listen to the crew and air traffic control
17:38discuss the flight path around the weather,
17:41EFI?
17:42They hear something interesting.
17:46Okay.
17:47I got it back.
17:48Now it's back.
17:50Hey, press the button.
17:51It fixes everything.
17:52Some of the instrument displays must have gone blank.
17:58Man, they got them back right away.
18:00We heard that the first officer was having a little bit of an issue
18:06with his electronic flight instrument switching,
18:09but cycled that switch and basically cleared the problem.
18:12It's real clear on the other side of this weather,
18:19so there should be no problem getting to the airport.
18:22Okay.
18:22Giant 3591.
18:25Whoa.
18:29Where's my speed?
18:32My speed?
18:37We're stalling.
18:41Stop.
18:42Did the plane suddenly lose speed and stall?
18:49We know from the debris field
18:51that it hit the ground at a high speed.
18:55So which one is it?
19:02After searching muddy waters for more than a week,
19:06the flight data recorder of Atlas Airlines 3591
19:09is finally located
19:11and sent to Washington D.C. for processing.
19:15Everything was going smoothly
19:17until the first officer says,
19:20where's my speed?
19:21Three seconds later, he reports, we're stalling.
19:2515 seconds later, they crash.
19:28While investigators await flight data,
19:31Giant 3591.
19:33They review the intriguing lead from the plane's cockpit voice recording.
19:39My speed?
19:40It was pretty clear that the first officer was very agitated, very confused.
19:45We're stalling.
19:46We could hear him.
19:47We're stalling.
19:48We're stalling.
19:49Stalled?
19:50What's going on?
19:51Well, the plane was carrying nearly 26,000 pounds of cargo.
20:05Well, if any cargo came loose, it could have thrown off the plane's center of gravity.
20:09If freight breaks loose or moves in the cargo hold during flight,
20:17the center of gravity will shift,
20:19putting the plane off balance into an unrecoverable stall.
20:23In 2013, a Boeing 747 air freighter crashed in Afghanistan
20:30after poorly secured cargo rolled into the rear flight control systems during takeoff.
20:40Did shifting cargo on Atlas 3591 cause the plane to stall?
20:45We went to Miami to look at the loading process because, you know,
20:53cargo shift was another potential issue.
20:57Everything I've seen looks good.
21:00Can I have a look at the paperwork?
21:04We looked for potential vulnerabilities
21:08where either the cargo load may have not been properly secured
21:12or perhaps too much cargo may have been loaded
21:15or in the wrong position.
21:17So we looked at that pretty thoroughly.
21:20Looks like every pallet was well secured.
21:24And locking and loading was double checked.
21:30The center of gravity and specs look impeccable.
21:43Look at this.
21:45With shifting cargo eliminated as the cause of the stall,
21:52the team turns to a new piece of evidence for answers.
21:56This video comes from a county jail surveillance camera.
22:00The video captures the final seconds of Atlas 3591's flight.
22:06The first time I saw the security video,
22:09it was really disturbing because 767s just don't fly straight down like that.
22:14It really kind of deepened the mystery of what happened to that airplane.
22:20It's flying very fast, nose down,
22:23and it's not falling flat like a pancake.
22:28At that speed, it can't be stalling.
22:30Maybe the crew was trying to recover from one.
22:36The normal response to a stall in an aircraft is to lower the nose,
22:41lower the angle of attack, and increase power.
22:44The first officer says we're stalling 15 seconds before impact.
22:49Without the flight data in hand,
22:54investigators search for additional evidence that flight 3591 stalled before it crashed.
23:00How long is the plane speeding nose down in the video?
23:11Five seconds.
23:17We don't know what they're doing here.
23:19From the plane's configuration,
23:23investigators determined that Atlas 3591 could have been trying to recover from a stall.
23:30Maybe they just ran out of time trying to save it.
23:33Captain!
23:35What's going on?
23:36By the time they came out of the clouds and realized what was happening,
23:39it was too late, and the aircraft impacted the swamp.
23:43Pull up!
23:44We'll start with the beginning of the descent,
23:56about 14 minutes before impact.
23:59The flight data from Atlas Air 3591 is ready for analysis.
24:06The plane is beginning to descend here,
24:09about 110 miles from the airport.
24:11The pitch is normal.
24:14The plane's speed is consistent at 275 knots.
24:18Everything looks fine to this point.
24:20Let's just move ahead to the final minute of flight.
24:28Whoa.
24:29Okay.
24:31Something goes wrong right here.
24:35That's 32 seconds before the crash.
24:38Yeah.
24:38Where exactly does the first officer say the plane is stalling?
24:41Ugh.
24:47The first officer says we're stalling 15 seconds before impact.
24:53Hang on.
24:56There's no drop in airspeed.
24:58In fact, it's the opposite.
25:01270 knots.
25:02It's about double the 767's stall speed.
25:07See this?
25:09It's the angle of attack.
25:10It's 18 degrees, nose down.
25:13Nose down.
25:15There's no stick shaker alerts.
25:17The Boeing 767 has very good stall characteristics.
25:22If you're approaching a stall as imminent, the stick shaker will come on, number one.
25:26And there's a control column nudger that will actually push the nose forward to remind you that you're approaching a stall.
25:32Stalls typically happen at 16 to 20 degrees angle of attack, nose up.
25:37Where's my speed?
25:38Which this airplane was nowhere close to.
25:41My speed?
25:43The plane never stalled.
25:44We're stalling.
25:48When the first officer yelled out that the airplane was stalling...
25:51Stall!
25:52The airplane was nowhere near stalling.
25:56Atlas 3591...
25:58Pull up!
25:59...crashed for another reason.
26:04Check this out.
26:08Plane went into go-around mode.
26:10Go-around mode is an autopilot setting that increases thrust to about 80% of maximum power...
26:19...and pitches the nose up four degrees...
26:22...so the plane can go around rather than land.
26:26Typically a go-around is when you don't see the runway...
26:29...and you need to go-around and try another approach...
26:31...or it's directed by air traffic control.
26:35The crew doesn't mention a go-around.
26:37Ever.
26:39So if the crew never mentions a go-around...
26:41...did they initiate it by accident?
26:44Well, there's only one way to find out.
26:58Speedbrake?
26:59Go-around switch.
27:00Got it.
27:02Using Atlas 3591's flight data...
27:06...investigators recreate the pilot's actions...
27:08...up to the moment when the go-around mode is activated.
27:12Plane is descending normally.
27:17The autopilot and autothrottle are on.
27:21Pitch is nose up at one degree.
27:25We were trying to demonstrate a normal descent...
27:28...with the use of the speedbrake handles...
27:30...and we had a first officer in the right seat.
27:34Next, the speedbrakes are deployed to slow the plane.
27:45Check.
27:46The plane is slowing.
27:48When you extend the speedbrake in the 767...
27:51...there is no tone necessarily to let you know that it's out.
27:54Most airlines have the pilot flying...
27:56...keep their hand on the speedbrake lever...
27:58...as a tactile reminder that the speedbrake lever is out.
28:03Hang on.
28:05Look at your wrist.
28:07We noticed how close the first officer's wrist is...
28:11...to that go-around switch...
28:14...when they're manipulating the speedbrake handle...
28:16...per their procedures.
28:17Close, but I'm not hitting the go-around switch.
28:24What else is there?
28:26We then took a look at the timing...
28:28...of when the first officer was manipulating...
28:30...the speedbrake handle.
28:32They hit turbulence.
28:35Give it a bit of a bounce for turbulence.
28:42To the surprise of the investigator...
28:45...the pilot can inadvertently hit and activate the go-around mode.
28:50You must have felt to hit it.
28:53Nope.
28:55I didn't feel a thing.
28:57I hit it with my watch.
28:58There it is.
29:10There were social media photos...
29:17that indicated that he commonly wore a large silver wristwatch on his left wrist.
29:22It was sort of big and chunky and metal...
29:25...and he was likely wearing it during the accident flight.
29:31We're supposed to be on heading, yeah?
29:33As flight 3591 gets closer to the airport...
29:36...the pilots prepare for their final approach.
29:39We'll cut you due north for a base leg.
29:50Sounds good.
29:51Sounds good.
29:523591.
29:56His wrist would have been within an inch or so of these rocker switches.
29:59And if he was wearing this chunky metal watch...
30:02...that would have closed the distance further.
30:04So if he contacted the switch with that wristwatch...
30:08...it's quite possible he never even felt the contact.
30:15Looks like the crew inadvertently put the plane into go-around mode.
30:22You think this has happened before?
30:26I'll look through the pilot's reports.
30:31Investigators discover that inadvertent go-arounds do occur.
30:35We identified less than a dozen reports.
30:38However, I suspect this has happened a lot more often...
30:41...because crews usually detect and correct this problem quickly.
30:45When the go-around mode is activated...
30:47...the primary flight display lights up and alerts the pilot.
30:51It's hard to miss.
30:53It is clearly enunciated at the top of the primary flight display...
30:57...right in the pilot's vision...
30:59...and they should have seen that...
31:00...so we needed to see what was going on in the cockpit at that time.
31:04Whoa.
31:05Okay.
31:06Giant 3591.
31:11Investigators return to Atlas 3591's data.
31:15This is where go-around mode engages.
31:18Autopilot is on.
31:20To learn what the pilots were doing...
31:22...when they failed to notice the plane was in go-around mode.
31:25The plane's engines put out more power.
31:28The plane pitches up.
31:32But look at that.
31:34It pitches up for a bit.
31:37And then suddenly down.
31:40The only way for the plane to pitch down during a go-around would be for the pilot to override the automation.
31:47But the question is, why would a pilot do that?
31:48If he didn't realize that the go-around mode was activated, he might have felt that the plane was pitching too high.
31:58Investigators make a key discovery.
32:03Flying through thick cloud with no visual reference of the horizon, First Officer Asker experienced spatial disorientation.
32:14Once the go-around mode was activated, the thrust was accelerating the airplane and it began pitching up and of course they were in the clouds so he couldn't see the horizon.
32:24That effect gave the first officer the feeling that he was pitching up when he really wasn't pitching up as much as his inner ear was thinking.
32:34Well, that might explain why he reacted by pushing the plane nose down.
32:39So what's the captain doing?
32:41Now, wouldn't he be looking at the instruments?
32:46He's on the radio with air traffic control.
32:48Giant 3591 and about another 18 miles.
32:55We'll cut you due north for a baseline.
32:58Sounds good. Giant 3591.
33:02Okay, so when he was finished talking to ATC, surely he would look at the instruments.
33:08Investigators can't tell where the captain was looking at the time.
33:11But the FDR data can reveal what he was doing.
33:16Let's see what the elevators tell us.
33:18The elevator data reflects how the pilots handled their control columns to alter the pitch of the aircraft.
33:26They're working in tandem until the go-around mode is activated.
33:31Okay, look, only the captain's starts moving up.
33:36The captain must have noticed that the plane was nose down and pulled up.
33:40By the time he realized what was going on, their fate was sealed.
33:45Investigators discover the captain tried to pull the plane out of the dive,
33:53while First Officer Asker continued to push forward.
33:57Captain, what's going on?
33:59The airplane was pointed straight down, and at the last minute,
34:03they both were pulling back trying to save the airplane, but it was too low and too late.
34:09During training, it is drilled into the pilots to rely on their instruments and not on their senses.
34:14So why didn't he do what he was trained to do?
34:20I would have mercy upon myself.
34:24Pull up!
34:25Pull up!
34:25We got the training records from Atlas.
34:42Check this out.
34:45The team looks into the First Officer's training at Atlas Airlines
34:49to understand why he didn't rely on his instruments as he was trained to do.
34:56In 2017, the First Officer had difficulty completing normal procedures,
35:01thinking ahead,
35:03even troubleshooting.
35:06Looks like he failed the first checkride of the 767, too.
35:11The First Officer failed his initial oral examination for the 767 type rating.
35:17He then had difficulty during the flight training portion,
35:22and he had to receive some remedial training before he passed the checkride.
35:27The remedial training instructor felt the First Officer had a confidence problem.
35:40After seeing First Officer Asker's dismal training record with Atlas,
35:44the team digs further into his career.
35:47Now we need to go back and look into his history, his training.
35:51What could have led to this?
35:53How far back did these go?
35:55It's everything, from the start of his piloting career in 2008.
36:02Commute Air, Trans States, Mesa.
36:06How many airlines?
36:07Six other airlines over nine years.
36:09So as we look back into the history of this pilot,
36:14we started to find some interesting gaps
36:17and some interesting information in his training.
36:21Airspeed, whoa.
36:23Wait, wait, wait.
36:25Wait a second.
36:29Wow.
36:30This is unbelievable.
36:31Commute Air, incomplete training.
36:39It's the same story at Air Wisconsin.
36:41He resigns from both.
36:43Investigators looking into the crash of Atlas 3591
36:46discover a troubling work record for First Officer Asker.
36:50Both of those airlines, he actually failed to complete
36:54the First Officer training.
36:572014, he fails the oral exam, line check, and the check ride.
37:02In 2017, at Mesa Airlines,
37:04Asker trains to upgrade to the rank of captain.
37:12Approaching minimums.
37:13Approaching decision height.
37:17Minimums.
37:18What?
37:19That's not right.
37:21This first officer really struggled
37:23to pass training to upgrade to captain.
37:27Bloody hell.
37:29What's wrong with this plane?
37:31His trainer said that he had low situational awareness.
37:34He would get flustered, would get frantic.
37:37When unusual situations would come about,
37:39he would just press random buttons.
37:44The upgrade is unsuccessful, so he quits.
37:48This is one of the worst cases I've seen in my career.
37:53How does such a lousy pilot get a job flying for one of the biggest cargo delivery services on the planet?
37:59He had multiple episodes of poor performance, failed check rides, serious training deficiencies.
38:08So we went to Atlas Air and asked, what did you guys know?
38:12Why would Atlas Air Lines hire a pilot with such poor skills?
38:25Commute Air and Air Wisconsin aren't even on his CV.
38:28He said the gaps were because he was in college.
38:31There's nothing on this application about his unsuccessful upgrade attempt at Mesa or the failed line check at Trans States.
38:40Once we took a look at the first officer's resume and his application at Atlas Air,
38:50we found out that he had failed to disclose his history at other airlines.
38:54Pilots are expected to provide their training background and job history the same way that non-pilots are expected to provide all of their employment history.
39:08However, Aska did not include particularly troublesome training background and this misled future employers.
39:19He didn't tell them about most of this and Atlas never dug it up.
39:23How did this pilot manage to continue slipping through these cracks, retrain, move on, slip through another crack until eventually end up in the front end of a 767 and this accident?
39:40A minor slip-up turns to major disaster in 32 seconds.
39:47The airplane enters the clouds. It experiences turbulence.
39:51The first officers left wrist bumps the go-around switches. The airplane transitions to go-around mode.
40:06From the point that the go-around mode was activated, you had the first officer feeling the spatial disorientation, not watching his instrumentations, reacting inappropriately.
40:17Where's my speed?
40:21Counteracting the autopilot, he pushes forward on the control column.
40:24The airplane begins to enter a dive and accelerate further.
40:31My speed?
40:33We're stalling.
40:36Stalled!
40:38He's way behind the airplane.
40:39The situational awareness is very, very low.
40:41He perceives a stall when, in fact, they're in a steep dive.
40:45Captain!
40:46What's going on?
40:48By the time the captain realized what was going on and attempted to correct this by pulling back on the yoke, it was too late.
40:56Lord have mercy!
40:57Pull up!
40:58Pull up!
41:11I take these accidents personally.
41:13You know, I want to try and prevent them because I was an airline pilot.
41:17I was in these guys' shoes.
41:19I want this to not happen again.
41:21And for me, this accident was so preventable.
41:24In their final report, the NTSB issues a safety alert about the close proximity of the speed brake lever to the left go-around switch,
41:36which could inadvertently cause an activation.
41:39The board also recommends the implementation of a pilot's records database,
41:44which allows airlines to access an applicant's employment and training records,
41:49something the FAA had been rolling out at the time of the accident.
41:52The NTSB has advocated for the implementation of the pilot records database for over a decade,
41:59because there have been pilots with repeated performance problems that never made it into the record-keeping system.
42:05The way to improve that issue is to improve the record-keeping system.