All language subtitles for M.2003-S23E09-Delivery.to.Disaster.Atlas.Air.Flight.3591.WEBDL-1080pEAC3.5.1h264-PiTBULL_track4_[eng]

Wanna go east?

We'll go on the west side.

NARRATOR: A flight carrying cargo for the
online retailer Amazon falls from the sky.

(alarm blares)
(yells) What's going on?!

Lord have mercy upon myself.

NARRATOR: It crashes into a swamp
40 miles outside Houston, Texas.

There are no survivors.

ENGLISH: We literally had to shuffle
along with our feet and hands

in this water and mud
in order to find anything.

NARRATOR: As investigators attempt
to piece together the wreckage,

security footage gives
them a valuable lead.

767s just don't fly
straight down like that.

Could the sudden loss of
altitude have been deliberate?

LAWRENCE:
It's possible.

- Lord have mercy!
- BLAKELY (yells): Pull up!

GPWS:
Terrain. Terrain.

PILOT:
Mayday, mayday!

(alarm blares)
GPWS: Pull up!

(indistinct radio chatter)

You ready?

NARRATOR:
37-year-old First Officer Conrad Aska

has been a professional
pilot for four years.

He's at the controls of tonight's
flight, cruising at 35,000 feet.

(warning beep)
(alarm blares)

There's a sudden
decompression of the cabin.

Aska must descend immediately to 10,000
feet where there is breathable oxygen.

(thunder)
(alarm blares)

The number of warnings
proves overwhelming.

ASKA: Wait, wait. Give me a second. Um…
(bell rings)

(system powers down)

NARRATOR: This is day four of
training on this type of aircraft.

He really had trouble
managing difficult situations.

When you threw something at him,

he would be more likely to panic
rather than troubleshoot.

TECH (radio): Okay, Conrad. I'm gonna
reset to 35,000. Let's try this again.

NARRATOR: Two years later, while
working for Trans States Airlines,

First Officer Aska fails a check ride,

an oral exam, and a line
check on the Embraer Jet.

ENGLISH: He did react very
severely to minor disturbances.

Basic stuff, pilot 101,
instrument type of errors.

NARRATOR: Three years later, after
failing captain training at Mesa Airlines,

Aska's career is now in jeopardy.

(tense music)

Atlas Flight 3591 cruises
over the Gulf of Mexico.

Speed two-five-zero.

NARRATOR: 60-year-old Captain Ricky
Blakely has been a pilot for 17 years.

He is monitoring today's
flight to Houston, Texas.

6,000 is our bottom altitude.

NARRATOR: First Officer
Conrad Aska is at the controls.

There's a third off-duty pilot
on board hitching a ride.

Roger, 6,000.

NARRATOR:
The pilots are flying a Boeing 767-375.

GARDNER: It's what they call a BCF,
a Boeing converted freighter.

It used to be in passenger service
and then they removed all the seats,

cut a new cargo door, and then
it entered service as a freighter.

The 767 serves a lot of markets very well.

NARRATOR: The Boeing 767 is a
reliable, automated, wide-bodied plane

that has a load capacity of
52 tons for Atlas Air.

Atlas Air is a cargo and passenger airline
that flies for various contractors,

but their biggest customer is Amazon.

NARRATOR: Atlas 3591 took off from
Miami with 26,000 pounds of cargo.

It's a two-and-a-half-hour
flight to Houston.

All right. Confirm.

NARRATOR:
279 miles from their destination,

the pilots set a target
altitude for descent.

(beep)

ATC: Attention all aircraft,
hazardous information, Houston Center.

There's a weather advisory. It's
gonna be a bit choppy coming in.

BLAKELY:
Giant 3591, copy that.

NARRATOR: For today's flight,
Atlas Air's call sign is Giant 3591.

(hums) It could be a bumpy ride.

- Did you say something?
- Uh, no.

Okay, as far as my technique
to land this plane…

- It's hard to hear you, man.
- Oh. Okay.

As far as my technique to land this plane,
at 1,000 feet, I'll take autopilot off.

Okay. Good plan.

61 miles from the airport, the 767
continues its descent towards Houston.

(engine drones)

Giant 3591, Houston Center.

There is a light to heavy precipitation
west of Dayton, moving eastbound.

NARRATOR: A few minutes later,
the controller updates the crew.

GARDNER: There was a cold front that was
moving from the northwest to the southeast

that they would have to navigate around.

This was just a routine cold front. No
convective activity to really worry about.

All right, thanks for the
heads up, Giant 3591.

How do you wanna get around this stuff?

Cut to the east of it and
join up on the north side?

One second, I'll get right back with you.

- Your controls.
- Great. My controls.

NARRATOR: The first officer
hands control to the captain

while he considers his route
around the precipitation.

GARDNER: Somebody always
needs to be flying the airplane.

So the pilot flying, if he
needs to do something,

will hand off the controls to
the pilot monitoring

and then they switch roles at that point.

- ASKA: Uh… (hums)
- Wanna go east?

Giant 3591, we'll go on the west side.

Uh… The only problem is there's a
bunch of departures in the west…

But if you hustle all the way down to
3,000… I can get you west of this weather.

GARDNER:
The crew decided to go west.

Air traffic control's got departures
coming out of the airport

so they did ask them to
hurry on down to 3,000 feet.

NARRATOR: Captain Blakely
sets the new target altitude.

3,000. Set.

NARRATOR: The autopilot begins descent
earlier to reach the target altitude.

To slow the plane, the First Officer
deploys the speed brakes.

GARDNER: It actually puts an air
foil up on the wing of the airplane

that will slow the airplane down.

It'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.

(engine drones)

NARRATOR:
As the plane continues toward Houston…

EFI.

NARRATOR: The first officer notices that
one of his flight displays has gone blank.

The EFI, or Electronic Flight
Instrument System,

displays vital flight and
performance data.

- Okay, I've got it back.
- Now it's back.

Yeah, press a button, it fixes everything.

(Blakely chuckles)

If there's some problem with
the display in front of you,

what you want to do is cycle it.

It'll switch to the center

and then it brings it back to
your own side of the aircraft.

All right, your controls.

My controls.

NARRATOR: The captain hands
control back to First Officer Aska.

Okay, flaps one.

NARRATOR: 40 miles from the airport, the
crew configures the plane for landing.

GARDNER:
Every time you approach an airport

it could be different configurations,
different runways you're landing on.

So it's always good to get
ahead of the airplane

and prepare for the approach
as soon as you possibly can.

That way, you've got a mental
picture of what's going on

as you enter the terminal area.

We're supposed to be on heading, yeah?

NARRATOR:
As Flight 3591 gets closer to the airport,

the pilots prepare for
their final approach.

ATC: Giant 3591, in about another 18 miles
we'll cut you due north for a base leg.

It's real clear on the other
side of this weather

so there should be no
problem getting to the airport.

NARRATOR: The controller informs the
crew that he'll direct the plane north

after they divert around the weather.

Okay, Giant 3591.

ASKA:
Where's my speed?

My speed!

(engine drones)
(dramatic music)

We're stalling. Stall!

(alarm blares)

- (yells) What's going on?!
- Lord have mercy upon myself.

- (yells) Lord have mercy! Captain!
- BLAKELY (yells): Pull up!

NARRATOR: The pilots of Flight 3591
struggle to recover the plane…

but they're too late.

Atlas Air 3591 has crashed into
the marshy waters of Trinity Bay,

40 miles east of Houston.

(somber music)

There are no survivors.

26,000 pounds of cargo
has sunk into swamp mud.

A team from the NTSB, the National
Transportation Safety Board,

wades through the marsh
to salvage the wreckage.

ENGLISH: We've had deep water. We've
had forests and jungles and wide areas.

But this combined pretty much everything
to make it one of the most difficult,

time consuming, and challenging recoveries
I'd seen in all my years at the Board.

NARRATOR: While the painstaking
recovery effort continues,

NTSB Investigator Bill English sets up an
operations base in nearby Baytown, Texas.

Take a look at the debris field.

NARRATOR: NTSB investigator
David Lawrence joins the team.

He has worked on more
than 300 air accidents.

- Split into a million pieces.
- You know what that means.

Looking at the debris field and
how disintegrated everything was,

you could tell that this airplane came
at a high velocity into the ground.

It was a high energy impact.

- Any news on the recorders?
- Not yet.

NARRATOR: The plane's recorders are key to
solving the mystery of Atlas 3591's crash,

but the splintered wreckage
won't make them easy to find.

ENGLISH: The wreckage was
completely or partially submerged

in this mud and silt-filled water

and we literally had to shuffle
along with our feet and hands

in order to find anything.

We didn't know if we were ever gonna
recover the flight recorders.

ATC: I pulled the data on Atlas 3591 and
the transcript of our radio exchange.

NARRATOR: While the team waits
for the recorders to be recovered,

David Lawrence speaks to the controller
who directed the plane towards Houston.

LAWRENCE: I wanted to hear the pilots
and the last conversations they had

and the last control instructions
air traffic had with the accident flight.

ATC:
There's also this.

(sighs) It looks like it
could get bumpy in there.

Did the crew mention lightning
or if they were struggling?

Uh-uh.

There was a cold front that was
moving through the Houston vicinity,

but nothing that would knock a
767 out of the sky that morning.

What about distress signals?
Any communications of that sort?

Nope, nothing. See here?
I gave them the weather info,

they said okay, and I didn't
hear from them after that.

LAWRENCE:
There was no mayday call.

Their communications were standard
and normal with air traffic control,

so there was no indication that there
was a problem with the airplane.

ATC: Here's the final few
minutes of the plane's track.

- See? Here. The altitude dropped quickly.
- LAWRENCE: Yeah.

NARRATOR: Investigators don't
know why Atlas 3591 crashed,

but its sudden dive gives them a clue.

Well, thanks. I'll be in touch
if I have more questions.

The airplane, as it was
descending towards 6,000 feet,

suddenly began a very steep dive
straight down to the ground.

NARRATOR: With weather eliminated
as a reason for the crash…

Maybe it's a flight control problem.

NARRATOR: Investigators turn
to the wreckage for clues.

Let's see if we can find the jackscrew.

NARRATOR: A jackscrew inside the tail
controls the horizontal stabilizer.

As the jackscrew turns,

it moves the stabilizer up and down
to adjust the pitch of the aircraft.

Looks like most of it is here.

DAVID:
Well, it's banged up from the impact,

but there's no evidence of excessive
wear, no stripped threads.

11.25 inches.

Nothing unusual here.

The position of the
controls on the jackscrew

was consistent with pilot type control
inputs, not some kind of runaway.

LAWRENCE: Let's take a look at
the plane's descent profile.

NARRATOR:
With a runaway stabilizer ruled out,

investigators return
to the plane's descent.

Well it's a normal descent
until here, about 6,000 feet.

ENGLISH: Could the sudden loss of
altitude have been deliberate?

NARRATOR: The plane's track has the
chilling hallmarks of a deliberate act.

It's possible.

BRAMBLE:
In the past,

pilots have purposefully crashed the
airplane due to psychological problems.

NARRATOR: In 2015, the first
officer on a Germanwings Airbus

locked the captain out of the cockpit,
increased the aircraft's speed,

and deliberately crashed the
plane into the French Alps,

killing all 150 people on board.

Two years earlier, a LAM Mozambique flight
crashed in Namibia, killing 33 people,

after the captain altered the autopilot
to fly the plane into the ground.

Both these incidents, the pilots were
dealing with some serious issues.

I'll get our crew's medical records.

NARRATOR: As the team looks into the
mental health of Atlas 3591's crew,

they receive news
from the recovery effort.

They found the cockpit voice recorder.

NARRATOR: The cockpit voice recorder is
sent to Washington D.C. for processing.

Captain's medical file.

- There's no issues here.
- He passed his medical checks.

No history of depression or any
other major personal issues.

LAWRENCE:
What about the first officer?

He passed all his medical tests.

BRAMBLE: There was nothing in the
medical histories of these pilots

that was a red flag for an
intentional act-type scenario.

ENGLISH:
Ah. Good timing, thanks.

NARRATOR: The cockpit voice
recording should shed light

on why Atlas 3591 was in
a high-speed descent.

BLAKELY:
Speed two-five-zero.

- 6,000 is our bottom altitude.
- ASKA: Roger. 6,000.

They're discussing target altitude,
pretty standard stuff.

I don't detect any stress in their voices.

None. Fast forward a little bit.

BLAKELY: All right, thanks
for the heads up. Giant 3591.

How do you wanna get around this stuff?

Cut to the east of it and join
up on the north side?

One second, I'll get right back with you.

Wanna go east?

NARRATOR: As investigators listen
to the crew and Air Traffic Control

discuss the flight
path around the weather…

EFI.

NARRATOR:
They hear something interesting.

- ASKA: Okay, I got it back.
- Now it's back.

Yeah, press a button, it fixes everything.

(Blakely chuckles)

So the instrument
displays must have gone blank.

And they got them back right away.

ENGLISH: We heard that the first officer
was having a little bit of an issue

with his electronic flight
instrument switch,

but cycled that switch and
basically cleared the problem.

ATC: It's real clear on the
other side of this weather,

so there should be no
problem getting to the airport.

Okay, Giant 3591.

Whoa.

Where's my speed?

My speed?

(dramatic music)

We're stalling.

Stall!

Did the plane suddenly
lose speed and stall?

We know from the debris field that
it hit the ground at a high speed.

So which one is it?

NARRATOR: After searching muddy
waters for more than a week,

the flight data recorder of Atlas
Airlines 3591 is finally located

and sent to Washington, D.C.
for processing.

Everything was going smoothly until the
first officer says, "Where's my speed?"

Three seconds later he
reports, "We're stalling."

ENGLISH:
15 seconds later they crash.

NARRATOR:
While investigators await flight data…

Giant 3591.

NARRATOR:
They review the intriguing lead…

Where's my speed?

NARRATOR:
From the plane's cockpit voice recording.

My speed?

ENGLISH:
It was pretty clear

that the first officer was
very agitated, very confused.

We're stalling.

We could hear him.
"We're stalling, we're stalling."

- Stall!
- (yells) What's going on?!

Okay. Let's assume it stalled. How come?

Well, the plane was carrying…
nearly 26,000 pounds of cargo.

Well, if any cargo came loose,

it could have thrown off
the plane's center of gravity.

NARRATOR: If freight breaks loose or
moves in the cargo hold during flight,

the center of gravity will shift,

putting the plane off balance
into an unrecoverable stall.

In 2013, a Boeing 747 air freighter
crashed in Afghanistan

after poorly secured cargo rolled
into the rear flight control systems

during takeoff.

Did shifting cargo on Atlas
3591 cause the plane to stall?

BRAMBLE: We went to Miami to
look at the loading process

because, you know, cargo shift
was another potential issue.

Everything I've seen looks good.

Can I have a look at that paperwork?

We looked for potential vulnerabilities,

where either the cargo load may
have not been properly secured,

or perhaps too much cargo may have
been loaded, or in the wrong position.

So we looked at that pretty thoroughly.

It looks like every pallet
was well secured,

and locking and loading
was double checked.

The center of gravity
and specs look impeccable.

Look at this.

NARRATOR: With shifting cargo
eliminated as the cause of the stall,

the team turns to a new
piece of evidence for answers.

This video comes from a
county jail surveillance camera.

NARRATOR: The video captures the
final seconds of Atlas 3591's flight.

LAWRENCE:
The first time I saw the security video,

it was really disturbing, because 767s
just don't fly straight down like that.

It really kinda deepened the mystery of
what happened to that airplane.

ENGLISH: It's flying very fast, nose-down,
and it's not falling flat like a pancake.

At that speed, it can't be stalling.

Maybe the crew was
trying to recover from one.

ENGLISH: The normal response to a
stall in an aircraft is to lower the nose,

lower the angle of
attack and increase power.

The First Officer says we're stalling 15
seconds before impact.

NARRATOR:
Without the flight data in hand,

investigators search for additional
evidence that Flight 3591 stalled

before it crashed.

How long is the plane
speeding nose-down in the video?

Five seconds.

LAWRENCE:
We don't know what they're doing here.

NARRATOR: From the plane's configuration,
investigators determine that Atlas 3591

could have been trying
to recover from a stall.

Maybe they just ran out
of time trying to save it.

- (yells) Captain!
- (yells) What's going on?!

(alarm blares)

ENGLISH: By the time they came out of the
clouds and realized what was happening,

it was too late, and the
aircraft impacted the swamp.

BLAKELY (yells): Pull up!
(alarm blares)

We'll start with the beginning of the
descent, about 14 minutes before impact.

NARRATOR: The flight data from
Atlas Air 3591 is ready for analysis.

ENGLISH: The plane is beginning to descend
here, about 110 miles from the airport.

LAWRENCE: The pitch is normal. The
plane's speed is consistent at 275 knots.

ENGLISH:
Everything looks fine to this point.

Let's just move ahead
to the final minute of flight.

Whoa. Okay, something
goes wrong right here.

LAWRENCE:
That's 32 seconds before the crash.

ENGLISH: Yeah. Where exactly does the
First Officer say the plane is stalling?

(Lawrence grunts)

The First Officer says "We're stalling"
15 seconds before impact.

Hang on.

There's no drop in airspeed.

- In fact, it's the opposite.
- 270 knots.

That's about double the 767's stall speed.

And see this? It's the angle of attack.
It's 18 degrees, nose-down.

Nose-down. There's no stick shaker alert.

GARDNER: The Boeing 767
has very good stall characteristics.

If you're approaching a
stall that's imminent,

the stick shaker will come on, number one.

And there's a control column nudger
that will actually push the nose forward

to remind you that
you're approaching a stall.

Stalls typically happen at 16 to 20
degrees angle of attack nose-up…

Where's my speed?

…which this airplane was nowhere close to.

- My speed?
- The plane never stalled.

We're stalling.

BRAMBLE: When the first officer yelled
out that the airplane was stalling…

- Stall!
- …the airplane was nowhere near stalling.

- NARRATOR: Atlas 3591…
- BLAKELY (yells): Pull up!

NARRATOR:
…crashed for another reason.

(alarm blares)

LAWRENCE:
Check this out.

The plane went into Go-Around mode.

NARRATOR:
Go-Around mode is an autopilot setting

that increases thrust to about
80% of maximum power

and pitches the nose-up four degrees, so
the plane can go around rather than land.

GARDNER: Typically a go-around is
when you don't see the runway

and you need to go around
and try another approach,

or it's directed by air traffic control.

And the crew doesn't
mention a go-around. Ever.

So if the crew never mentions a go-around…
did they initiate it by accident?

Well, there's only one way to find out.

- Speed brake. Go-Around switch.
- Got it.

NARRATOR: Using Atlas 3591's flight data,
investigators recreate the pilots' actions

up to the moment when the
Go-Around mode is activated.

The plane is descending normally.

The auto-pilot and auto throttle are on.
Pitch is nose-up at one degree.

We were trying to demonstrate
a normal descent

with the use of the speed brake handles

and we had a first
officer in the right seat.

Next, the speed brakes are
deployed to slow the plane.

Check. The plane is slowing.

GARDNER:
When you extend the speed brake in a 767,

there is no tone necessarily to
let you know that it's out.

Most airlines have the pilot flying keep
their hand on the speed brake lever

as a tactile reminder
that the speed brake lever is out.

Hang on. Look at your wrist.

We noticed how close the first officer's
wrist is to that Go-Around switch

when they're manipulating the
speed brake handle per their procedures.

Close, but I'm not hitting
the Go-Around switch.

(sighs) What else is there?

We then took a look at the timing

of when the first officer was
manipulating the speed brake handle.

They hit turbulence. Give it a
bit of a bounce for turbulence.

NARRATOR:
To the surprise of the investigator,

the pilot can inadvertently hit and
activate the Go-Around mode.

You must have felt it hit it.

Nope. I didn't feel a thing.
I hit it with my watch.

There it is.

That explains it.

BRAMBLE: There were social
media photos that indicated

that he commonly wore a large
silver wristwatch on his left wrist.

It was sort of big and chunky and metal,

and he was likely wearing
it during the accident flight.

We're supposed to be on heading, yeah?

NARRATOR:
As Flight 3591 gets closer to the airport,

the pilots prepare for
their final approach.

ATC: Giant 3591, in about another 18 miles
we'll cut you due north for a base leg.

Sounds good. Giant 3591.

BRAMBLE: His wrist would have been within
an inch or so of these rocker switches.

And if he was wearing this
chunky metal watch,

that would have closed
the distance further.

So if he contacted the switch
with that wristwatch,

it's quite possible he never
even felt the contact.

Looks like the crew inadvertently
put the plane into Go-Around mode.

You think this has happened before?

I'll look through the pilots' reports.

NARRATOR: Investigators discover that
inadvertent Go-Arounds do occur.

BRAMBLE:
We identified less than a dozen reports.

However, I suspect this has
happened a lot more often

because crews usually detect and
correct this problem quickly.

When the Go-Around mode is activated,

the primary flight display
lights up and alerts the pilot.

Yeah, it's hard to miss.

It is clearly enunciated at the top of
the primary flight display,

right in the pilots' vision, and
they should have seen that.

So we needed to see what was
going on in the cockpit at that time.

- Whoa.
- Okay. Giant 3591.

NARRATOR:
Investigators return to Atlas 3591's data…

- This is where Go-Around mode engages.
- Autopilot is on.

NARRATOR:
…to learn what the pilots were doing

when they failed to notice the
plane was in Go-Around mode.

LAWRENCE:
The plane's engines put out more power.

The plane pitches up but look at that.

It pitches up for a bit
and then suddenly down.

NARRATOR: The only way for the plane
to pitch down during a go-around

would be for the pilot
to override the automation.

But the question is, why
would a pilot do that?

If he didn't realize that the
Go-Around mode was activated,

he might have felt that the
plane was pitching too high.

NARRATOR:
Investigators make a key discovery.

Flying through thick cloud with
no visual reference of the horizon,

First Officer Aska experienced
spatial disorientation.

LAWRENCE:
Once 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.

That 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.

Well, that might explain why he reacted
by pushing the plane nose-down.

So what's the captain doing? Now wouldn't
he be looking at the instruments?

He's on the radio
with Air Traffic Control.

ATC:
Giant 3591, in about another 18 miles,

- we'll cut you due north for a base leg.
- Sounds good, Giant 3591.

Okay, so when he was
finished talking to ATC,

surely he would look at the instruments.

NARRATOR: Investigators can't tell where
the captain was looking at the time,

but the FDR data can reveal
what he was doing.

Well, let's see what
the elevators tell us.

NARRATOR: The elevator data reflects how
the pilots handled their control columns

to alter the pitch of the aircraft.

They're working in tandem until the
Go-Around mode is activated.

Okay, look, only the
captain's starts moving up.

LAWRENCE:
The Captain must have noticed

that the plane was nose-down,
and pulled up.

By the time he realized what was going on…

…their fate was sealed.

NARRATOR:
Investigators discover

the captain tried to pull
the plane out of the dive

while First Officer Aska
continued to push forward.

- (yells) Captain!
- (yells) What's going on?!

LAWRENCE:
The airplane was pointed straight down.

And at the last minute, they both were
pulling back trying to save the airplane,

but it was too low and too late.

During training, it is
drilled into the pilots

to rely on their instruments
and not on their senses.

So why didn't he do
what he was trained to do?

Lord have mercy upon myself.
(alarm blares)

- BLAKELY (yells): Pull up!
- GPWS: Pull up.

(dramatic music)

I got the training records from Atlas.

Check this out.

NARRATOR: The team looks into the first
officer's training at Atlas Airlines

to understand why he didn't rely on his
instruments as he was trained to do.

In 2017, the first officer had difficulty
completing normal procedures,

thinking ahead,

even troubleshooting.

Looks like he failed the first
check ride on the 767 too.

BRAMBLE: The first officer
failed his initial oral examination

for the 767 type rating.

He then had difficulty during
the flight training portion

and he had to receive some remedial
training before he passed the check ride.

The remedial training instructor felt the
first officer had a confidence problem.

NARRATOR: After seeing First Officer
Aska's dismal training record with Atlas,

the team digs further into his career.

Now we need to go back and
look into his history, his training.

What could have led to this?

How far back do these go?

It's everything from the start
of his piloting career in 2008.

CommutAir, Trans States,
Mesa. How many airlines?

Six other airlines over nine years.

So as we looked back into
the history of this pilot,

we started to find some interesting gaps

and some interesting
information in his training.

(thunder)
(warning beep)

COMPUTER:
Airspeed low.

(alarm blares)

ASKA:
Wait, wait, wait. Give me a second. Um…

(ringing)
(system powers down)

Wow. This is unbelievable.

CommutAir. Incomplete training.

It's the same story at Air Wisconsin.
He resigns from both.

NARRATOR: Investigators looking
into the crash of Atlas 3591

discover a troubling work
record for First Officer Aska.

Both those airlines, he actually failed to
complete the first officer training.

2014. He fails an oral exam,
line check, and a check ride.

In 2017, at Mesa Airlines, Aska trains
to upgrade to the rank of captain.

COMPUTER: Approaching minimums.
Approaching decision height.

(alarm blares)

- COMPUTER: Minimums.
- What? That's not right.

RACHEL:
This first officer really struggled

to pass training to upgrade to captain.

Bloody hell. What's wrong with this plane?

RACHEL: His trainers said that
he had low situational awareness.

He would get flustered, would get frantic,

when unusual situations would come
about, he would just press random buttons.

ENGLISH: And the upgrade is
unsuccessful, so he quits.

This is one of the worst
cases I've seen in my career.

How does such a lousy pilot get a job

flying for one of the biggest cargo
delivery services on the planet?

LAWRENCE: He had multiple
episodes of poor performance,

failed check rides,
serious training deficiencies.

So we went to Atlas Air and
asked, "What did you guys know?"

Finally, a CV and his
Atlas Air job application.

NARRATOR: Why would Atlas Airlines
hire a pilot with such poor skills?

CommutAir and Air
Wisconsin aren't even on his CV.

He said the gaps were
because he was in college.

There's nothing on this application about
his unsuccessful upgrade attempt at Mesa,

or the failed line check at Trans States.

Once we took a look at
the first officer's resume

and his application at Atlas Air,

we found out that he had failed to
disclose his history at other airlines.

(alarm blares)
ASKA: Wait. Give me a second. Um…

RACHEL: Pilots 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.

However, Aska did not include particularly
troublesome training background

and this misled future employers.

He didn't tell them about most of
this, and Atlas never dug it up.

How 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?

A minor slip-up turns to
major disaster in 32 seconds.

(engine drones)

BRAMBLE: The airplane enters the clouds.
It experiences turbulence.

The first officer's left wrist
bumps the Go-Around switches.

The airplane transitions
to Go-Around mode.

Whoa.

From the point that the
Go-Around mode was activated,

you had the first officer feeling
the spatial disorientation,

not watching his instrumentations,
reacting inappropriately.

Where's my speed?

BRAMBLE: Counteracting the autopilot, he
pushes forward on the control column.

The airplane begins to enter a
dive and accelerate further.

My speed?

We're stalling.

Stall!

GARDNER: He's way behind the airplane. The
situational awareness is very, very low.

He perceives a stall when, in
fact, they're in a steep dive.

- (yells) Captain!
- (yells) What's going on?

ENGLISH: By the time the captain
realized what was going on,

and attempted to correct this by pulling
back on the yoke, it was too late.

- Lord have mercy!
- GPWS: Pull up!

- BLAKELY (yells): Pull up!
- GPWS: Terrain. Terrain.

GPWS:
Pull up. Pull up.

LAWRENCE:
I take these accidents personally.

You know, I want to try and prevent 'em,

because I was an airline pilot,
I was in these guys' shoes.

I want this to not happen again. And for
me, this accident was so preventable.

NARRATOR: In their final report,
the NTSB issues a safety alert

about the the close proximity of the speed
brake lever to the left Go-Around switch,

which could inadvertently
cause an activation.

The Board also recommends
the implementation

of a pilots' records database,
which allows airlines to access

an applicant's employment
and training records,

something the FAA had been rolling
out at the time of the accident.

BRAMBLE: The NTSB has
advocated for the implementation

of the Pilot Records Database
for over a decade,

because there have been pilots with
repeated performance problems

that never made it into the
record-keeping system.

The way to improve that issue is to
improve the record-keeping system.