Original subtitles

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.