Original subtitles

Want to go east?

We'll go on the west side.

A flight carrying cargo for the online retailer

A flight carrying cargo for the online retailer

Amazon falls from the sky.

What's going on?

What's going on?

Lord, have mercy upon myself.

It crashes into a swamp 40 miles

It crashes into a swamp 40 miles

outside Houston, Texas.

There are no survivors.

There are no survivors.

We literally had to shuffle along

with our feet and hands in this water and mud

in order to find anything.

in order to find anything.

As investigators attempt

to piece together the wreckage, security footage

to piece together the wreckage, security footage

gives them a valuable lead.

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

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

Could the sudden loss of altitude have been deliberate?

It's possible.

It's possible.

Lord have mercy.

Pull up!

Ladies and gentlemen,

we are starting our approach.

we are starting our approach.

We lost both engines.

Mayday.

Mayday.

Brace for impact!

Brace for impact!

I think I lost one.

He's gonna crash!

He's gonna crash!

You ready?

37-year-old First Officer

37-year-old First Officer

Conrad Aska has been a professional pilot

for four years.

for four years.

He's at the controls of tonight's flight,

cruising at 35,000 feet.

There's a sudden decompression of the cabin.

There's a sudden decompression of the cabin.

Asks must descend immediately to 10,000 feet, where

there is breathable oxygen.

there is breathable oxygen.

The number of warnings proves overwhelming.

The number of warnings proves overwhelming.

Wait. Wait.

Wait.

Give me a second.

Um...

Um...

This is day four of training

on this type of aircraft.

He really had trouble managing difficult situations.

He really had trouble managing difficult situations.

When you threw something at him, he

When you threw something at him, he

would be more likely to panic rather than troubleshoot.

INSTRUCTOR (ON RADIO): OK, Conrad,

INSTRUCTOR (ON RADIO): OK, Conrad,

I'm gonna reset to 35,000.

Let's try this again.

Two years later, while working for Trans States

Airlines, First Officer Aska fails

Airlines, First Officer Aska fails

a check ride, an oral exam, and a line

check on the Embraer jet.

check on the Embraer jet.

He did react very severely to minor disturbances,

He did react very severely to minor disturbances,

basic stuff, Pilot 101 instrument type of errors.

basic stuff, Pilot 101 instrument type of errors.

Three years later, after failing

Three years later, after failing

captain training at Mesa Airlines, Aska's career

is now in jeopardy.

is now in jeopardy.

Atlas Flight 3591 cruises over the Gulf of Mexico.

Speed, 250.

60-year-old Captain Ricky Blakeley

60-year-old Captain Ricky Blakeley

has been a pilot for 17 years.

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

6,000 is our bottom altitude.

First Officer Conrad Aska is at the controls.

First Officer Conrad Aska is at the controls.

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

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

Roger, 6,000.

The pilots are flying a Boeing 767-375.

The pilots are flying a Boeing 767-375.

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

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 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.

The 767 serves a lot of markets very well.

The Boeing 767 is a reliable,

automated, wide bodied plane.

automated, wide bodied plane.

The Atlas Air version has a load capacity of 52 tons.

Atlas air is a cargo and passenger airline that

Atlas air is a cargo and passenger airline that

flies for various contractors.

But their biggest customer is Amazon.

But their biggest customer is Amazon.

Atlas 3591 took off from Miami

with 26,000 pounds of cargo.

with 26,000 pounds of cargo.

It's a 2 and 1/2 hour flight to Houston.

It's a 2 and 1/2 hour flight to Houston.

All right.

Confirm.

279 miles from their destination, the pilots set

279 miles from their destination, the pilots set

a target altitude for descent.

Attention all aircraft.

Hazardous information, Houston center.

Hazardous information, Houston center.

There's a weather advisory.

It's going to be a bit choppy coming in.

- ACTOR AS RICKY - Giant 3591.

- ACTOR AS RICKY - Giant 3591.

Copy that.

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

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

Hmm.

It could be a bumpy ride.

It could be a bumpy ride.

You say something?

No.

OK.

OK.

As far as my technique to land this plane...

It's hard to hear you, man.

It's hard to hear you, man.

Oh, OK.

As far as my technique to land this plane at 1,000 feet,

I'll take autopilot off.

I'll take autopilot off.

OK.

It's a good plan.

61 miles from the airport,

61 miles from the airport,

the 767 continues its descent towards Houston.

Giant 3591, Houston Center.

There is a light to heavy precipitation

There is a light to heavy precipitation

west of Dayton, moving eastbound.

A few minutes later, the controller updates

A few minutes later, the controller updates

the crew.

There was a cold front that was moving

from the Northwest to the Southeast

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.

Giant 3591.

How do you want to get around this stuff,

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

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.

My controls.

The first officer hands control to the captain

while he considers his route around the precipitation.

while he considers his route around the precipitation.

Somebody always needs

to be flying the airplane.

to be flying the airplane.

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

will hand off the controls to the pilot monitoring.

will hand off the controls to the pilot monitoring.

And then they switch roles at that point.

Uh, hmm...

Uh, hmm...

Want to go east?

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

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

Uh, the only problem is there's a bunch

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.

I can get you west of this weather.

The crew decided to go west.

Air traffic control has got departures

coming out of the airport.

coming out of the airport.

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

Captain Blakeley sets the new target altitude.

Captain Blakeley sets the new target altitude.

3,000, set.

The autopilot begins descent earlier

to reach the target altitude.

To slow the plane, the first officer

deploys the speed brakes.

That actually puts an airfoil

up on the wing of the airplane that

will slow the airplane down.

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.

with a clean wing.

As the plane continues toward Houston...

EFI?

EFI?

...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.

displays vital flight and performance data.

OK.

I got it back.

Now it's back.

Yeah.

I pressed the button that fixes everything.

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

what you want to do is cycle it.

what you want to do is cycle it.

It'll switch to the center, and then brings it back to

your own side of the aircraft.

your own side of the aircraft.

All right.

Your controls.

My controls.

The captain hands control

The captain hands control

back to First Officer Aska.

OK.

OK.

Flaps 1.

40 miles from the airport, the crew

configures the plane for landing.

configures the plane for landing.

Every time you approach an airport it could

be different configurations, different runways

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.

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

That way you've got a mental upstairs

picture of what's going on as you enter the terminal area.

We're supposed to be on heading.

We're supposed to be on heading.

Yeah?

As Flight 3591 gets closer to the airport,

As Flight 3591 gets closer to the airport,

the pilots prepare for their final approach.

Giant 3591, in about another 18 miles

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

whether, so there should be no problem getting to the airport.

The controller informs the crew

The controller informs the crew

that he'll direct the plane north after they

divert around the weather.

divert around the weather.

OK.

Giant 3591.

Giant 3591.

Where's my speed?

My speed?

We're stalling.

Stall.

What's going on?

Lord, have mercy upon myself.

Lord, have mercy.

Lord, have mercy.

Captain!

Pull up!

The pilots of flight 3591 struggle

to recover the plane, but they're too late.

to recover the plane, but they're too late.

Atlas Air 3591 has crashed

Atlas Air 3591 has crashed

into the marshy waters of Trinity Bay, 40 miles east

of Houston.

of Houston.

There are no survivors.

There are no survivors.

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

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.

Safety Board, wades through the marsh to salvage the wreckage.

We've had deep water.

We've had forests, and jungles, and wide areas.

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,

to make it one of the most difficult, time consuming,

and challenging recoveries I'd seen in all my years

at the Board.

While the painstaking recovery effort continues,

NTSB investigator Bill English sets up an operations

NTSB investigator Bill English sets up an operations

base in nearby Baytown, Texas.

Take a look at the debris field.

NTSB investigator David Lawrence joins the team.

NTSB investigator David Lawrence joins the team.

He has worked on more than 300 air accidents.

He has worked on more than 300 air accidents.

Split into a million pieces.

You know what that means.

You know what that means.

Looking at the debris field and how

disintegrated everything was, you

disintegrated everything was, you

could tell that this airplane came at a high velocity

into the ground.

It was a high energy impact.

It was a high energy impact.

Any news on the recorders?

Not yet.

Not yet.

The plane's recorders are key to solving the mystery

of Atlas 3591's crash.

of Atlas 3591's crash.

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

The wreckage was completely or partially submerged in this mud

and silt filled water.

and silt filled water.

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

in order to find anything.

in order to find anything.

We didn't know if we were ever going to recover

the flight recorders.

I pulled the data on Atlas 3591,

and the transcript of our radio exchange.

and the transcript of our radio exchange.

While the team waits for the recorders

to be recovered, David Lawrence speaks

to the controller who directed the plane towards Houston.

to the controller who directed the plane towards Houston.

I wanted to hear the pilots,

I wanted to hear the pilots,

and the last conversations they had,

and the last control instructions air traffic

had with the accident flight.

had with the accident flight.

It's also this.

Looks like it could get bumpy in there.

Looks like it could get bumpy in there.

Did the crew mention lightning or if they were struggling?

Uh-uh.

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

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.

Nope, nothing.

See here?

I gave them the weather info.

They said, OK, and I didn't hear from them after that.

They said, OK, and I didn't hear from them after that.

There was no mayday call.

Their communications were standard and normal with air

Their communications were standard and normal with air

traffic control.

So there was no indication that there was

a problem with the airplane.

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

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

See?

Here, the altitude dropped quickly.

Here, the altitude dropped quickly.

Yeah.

Investigators don't know why Atlas 3591 crashed.

Investigators don't know why Atlas 3591 crashed.

But its sudden dive gives them a clue.

Well, thanks.

Well, thanks.

I'll be in touch if I have more questions.

The airplane, as it was descending towards 6,000

The airplane, as it was descending towards 6,000

feet, suddenly began a very steep dive

straight down to the ground.

With weather eliminated

as a reason for the crash...

as a reason for the crash...

Maybe it's a flight control problem.

...investigators turned to the wreckage for clues.

Let's see if we can find the jack screw.

Let's see if we can find the jack screw.

A jack screw inside the tail controls

A jack screw inside the tail controls

the horizontal stabilizer.

As the jack screw turns, it moves

As the jack screw turns, it moves

the stabilizer up and down to adjust

the pitch of the aircraft.

Looks like most of it is here.

Well, it's banged up from the impact,

but there's no evidence of excessive wear,

no stripped threads.

no stripped threads.

11.25 inches.

11.25 inches.

There's nothing unusual here.

The position of the...

the controls on the jack screw was

the controls on the jack screw was

consistent with pilot-type control inputs,

not some kind of runaway.

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

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

With a runaway stabilizer ruled out,

investigators returned to the plane's descent.

investigators returned to the plane's descent.

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

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

Could the sudden loss of altitude have been deliberate?

The plains track has the chilling

The plains track has the chilling

hallmarks of a deliberate act.

It's possible.

It's possible.

In the past, pilots have purposefully crashed

the airplane due to psychological problems.

the airplane due to psychological problems.

In 2015, the first officer on a Germanwings Airbus

In 2015, the first officer on a Germanwings Airbus

locked the captain out of the cockpit,

increased the aircraft's speed, and deliberately crashed

increased the aircraft's speed, and deliberately crashed

the plane into the French Alps, killing

all 150 people on board.

all 150 people on board.

Two years earlier, a Lem Mozambique flight

Two years earlier, a Lem Mozambique flight

crashed in Namibia, killing 33 people,

after the captain altered the autopilot to fly

after the captain altered the autopilot to fly

the plane into the ground.

Both these incidents, the pilots

were dealing with some serious issues.

were dealing with some serious issues.

I'll get our crew's medical records.

I'll get our crew's medical records.

As the team looks into the mental health

of Atlas 3591's crew, they receive

news from the recovery effort.

news from the recovery effort.

They found the cockpit voice recorder.

The cockpit voice recorder is sent to Washington,

DC for processing.

DC for processing.

Captain's medical file.

There's no issues here.

He passed his medical checks.

There's no history of depression or any

There's no history of depression or any

other major personal issues.

What about the first officer?

He passed all his medical tests.

He passed all his medical tests.

There was nothing in the medical histories

of these pilots that was a red flag for an intentional act

type scenario.

type scenario.

Ah, good timing.

Ah, good timing.

Thanks.

The cockpit voice recording

should shed light on why Atlas 3591

should shed light on why Atlas 3591

was in a high speed descent.

- ACTOR AS RICKY - Speed, 250.

- ACTOR AS RICKY - Speed, 250.

6,000 is our bottom altitude.

- ACTOR AS CONRAD - Roger, 6,000.

- ACTOR AS CONRAD - Roger, 6,000.

They're discussing target altitude.

Pretty standard stuff.

Pretty standard stuff.

I don't detect any stress in their voices.

None.

Fast forward a little bit.

Fast forward a little bit.

- ACTOR AS RICKY - All right.

Thanks for the heads up.

Giant 3591.

How do you want to get around this stuff,

How do you want to get around this stuff,

cut to the east of it and join up on the other side?

One second.

I'll get right back with you.

I'll get right back with you.

Want to go east?

As investigators listened to the crew

and air traffic control discuss the flight

path around the weather...

EFI?

...they hear something interesting.

...they hear something interesting.

OK.

I got it back.

I got it back.

Now it's back.

Yeah.

I pressed the button that fixes everything.

Some of the instrument displays must have gone blank.

And they got them back right away.

a little bit of an issue with his electronic flight

a little bit of an issue with his electronic flight

instrument switch, but cycled that switch

and basically cleared the problem.

and basically cleared the problem.

It's real clear on the other side of this

whether, so there should be no problem getting to the airport.

OK.

Giant 3591.

Giant 3591.

Whoa.

Where's my speed?

My speed?

We're stalling.

Stall!

Did the plane suddenly lose speed and stall?

Did the plane suddenly lose speed and stall?

We know from the debris field that it

hit the ground at a high speed.

hit the ground at a high speed.

So which one is it?

Meanwhile, after a search in muddy waters for more

than a week, the flight data recorder

than a week, the flight data recorder

is recovered and sent to Washington, DC for processing.

is recovered and sent to Washington, DC for processing.

Everything was going smoothly until the first officer

says, where's my speed.

says, where's my speed.

Three seconds later, he reports we're stalling.

But 15 seconds later, they crash.

But 15 seconds later, they crash.

While investigators await flight data...

Giant 3591.

Giant 3591.

...they review the intriguing lead...

Where's my speed?

...from the plane's cockpit voice recorder.

...from the plane's cockpit voice recorder.

My speed?

It was pretty clear that the first officer was

very agitated, very confused.

very agitated, very confused.

We're stalling.

We could hear him.

We're stalling.

We're stalling.

Stall!

Stall!

What's going on?

OK.

Let's assume it stalled.

Let's assume it stalled.

How come?

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

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

Well, if any cargo came loose, it could have thrown off

Well, if any cargo came loose, it could have thrown off

the plane's center of gravity.

If freight breaks loose or moves in the cargo

hold during a flight, the center of gravity

will shift, putting the plane off balance

will shift, putting the plane off balance

into an unrecoverable stall.

into an unrecoverable stall.

In 2013, a Boeing 747 air freighter

crashed in Afghanistan after poorly secured

crashed in Afghanistan after poorly secured

cargo rolled into the rear flight control systems

during takeoff.

during takeoff.

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

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

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

We went to Miami to look at the loading process,

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

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

Everything I've seen looks good.

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

either the cargo load may have not been properly secured

or perhaps too much cargo may have been loaded

or in the wrong position.

or in the wrong position.

So we looked at that pretty thoroughly.

Looks like every pallet was well secured.

Looks like every pallet was well secured.

And locking and loading was double checked.

Center of gravity and specs look impeccable.

Center of gravity and specs look impeccable.

Look at this.

With shifting cargo eliminated as the cause

With shifting cargo eliminated as the cause

of the stall, the team turns to a new piece

of evidence for answers.

of evidence for answers.

This video comes from a county jail surveillance camera.

The video captures the final seconds

The video captures the final seconds

of Atlas 3591's flight.

The first time I saw the security video it was

The first time I saw the security video it was

really disturbing, because 767s just don't

fly straight down like that.

fly straight down like that.

It really kind of deepened the mystery of what

happened to that airplane.

happened to that airplane.

It was flying very fast, nose down,

and it's not falling flat like a pancake.

and it's not falling flat like a pancake.

At that speed, it can't be stalling.

At that speed, it can't be stalling.

Maybe the crew was trying to recover from one.

to a stall in an aircraft is to lower the nose.

Lower the angle of attack and increase power.

Lower the angle of attack and increase power.

The first officer says were stalling

15 seconds before impact.

15 seconds before impact.

Without the flight data in hand,

Without the flight data in hand,

investigators search for additional evidence

that Flight 3591 stalled before it crashed.

that Flight 3591 stalled before it crashed.

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

Five seconds.

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

From the plane's configuration,

From the plane's configuration,

investigators determined that Atlas 3591 could have been

trying to recover from a stall.

trying to recover from a stall.

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

Captain!

Captain!

What's going on?

and realized what was happening, it was too late.

and realized what was happening, it was too late.

And the aircraft impacted the swamp.

Pull up!

Let's start with the beginning of the descent,

Let's start with the beginning of the descent,

about 14 minutes before impact.

The flight data from Atlas Air 3591

The flight data from Atlas Air 3591

is ready for analysis.

The plane is beginning to descend here, about

The plane is beginning to descend here, about

110 miles from the airport.

The pitch is normal.

The pitch is normal.

The plane's speed is consistent at 275 knots.

Everything looks fine to this point.

Everything looks fine to this point.

Just move ahead to the final minute of flight.

Whoa.

OK.

OK.

Something goes wrong right here.

That's 32 seconds before the crash.

That's 32 seconds before the crash.

Where exactly does the first officer

say the plane is stalling?

First officer says we're stalling

First officer says we're stalling

15 seconds before impact.

Hang on.

There's no drop in air speed.

In fact, it's the opposite.

In fact, it's the opposite.

270 knots.

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

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

And see this?

It's the angle of attack.

It's 18 degrees, nose down.

It's 18 degrees, nose down.

Nose down.

There's no stick shaker alert.

There's no stick shaker alert.

The Boeing 767 has very

good stall characteristics.

If you're approaching a stall as imminent,

If you're approaching a stall as 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

push the nose forward to remind you that you're

approaching a stall.

Stalls typically happen at 16 to 20 degrees angle of attack,

Stalls typically happen at 16 to 20 degrees angle of attack,

nose up...

Where's my speed?

...which this airplane was nowhere close to.

...which this airplane was nowhere close to.

My speed?

Plane never stalled.

We're stalling.

When the first officer

yelled out that the airplane was stalling...

yelled out that the airplane was stalling...

Stall!

...the airplane was nowhere near stalling.

Atlas 3591...

Atlas 3591...

Pull up!

...crashed for another reason.

Check this out.

Plane went in to go around mode.

Plane went in to go around mode.

Go around mode is an autopilot setting

Go around mode is an autopilot setting

that increases thrust to about 80% of maximum power,

and pitches the nose up 4 degrees

and pitches the nose up 4 degrees

so the plane can go around rather than land.

so the plane can go around rather than land.

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.

by air traffic control.

The crew doesn't mention a go around ever.

The crew doesn't mention a go around ever.

So if the crew never mentions a go around,

did they initiate it by accident?

did they initiate it by accident?

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

Speed brake.

Go around switch.

Got it.

Got it.

Using Atlas 3591's flight data,

investigators recreate the pilot's

investigators recreate the pilot's

actions up to the moment when the go around mode

is activated.

is activated.

Plane is descending normally.

The autopilot and auto throttle are on.

The autopilot and auto throttle are on.

Pitch is nose up at 1 degree.

Pitch is nose up at 1 degree.

We were trying to demonstrate

a normal descent with the use of the speed brake handles.

a normal descent with the use of the speed brake handles.

And we had a first officer in the right seat.

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.

When you extend the speed break in a 767,

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

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

on the speed brake lever as a tactile reminder

that the speed brake lever is out.

Hang on.

Hang on.

Look at your wrist.

We noticed how close the first officer's 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.

manipulating the speed brake handle per their procedures.

Close, but I'm not hitting the go around switch.

What else is there?

We then took a look at the timing

We then took a look at the timing

of when the first officer was manipulating

the speed brake handle.

the speed brake handle.

They hit turbulence.

Give it a bit of a bounce for turbulence.

To the surprise of the investigator,

To the surprise of the investigator,

the pilot can inadvertently hit and activate

the go around mode.

the go around mode.

You must have felt it hit it.

Nope.

I didn't feel a thing.

I didn't feel a thing.

I hit it with my watch.

There it is.

That explains it.

There were social media photos that indicated

that he commonly wore a large silver

that he commonly wore a large silver

wristwatch on his left wrist.

It was sort of big, and chunky, and metal.

It was sort of big, and chunky, and metal.

And he was likely wearing it during the accident flight.

And he was likely wearing it during the accident flight.

We're supposed to be on heading.

Yeah?

As Flight 3591 nears the airport,

As Flight 3591 nears the airport,

the pilots prepare for their final approach.

Giant 3591, in about another 18 miles

Giant 3591, in about another 18 miles

we'll cut you due north for a base leg.

Sounds good.

Giant 3591.

Giant 3591.

His wrist would have been within an inch or so

of these rocker switches.

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,

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

Looks like the crew inadvertently put

the plane into go around mode.

Do you think this has happened before?

Do you think this has happened before?

I'll look through the pilot's reports.

Investigators discover that inadvertent go

arounds do occur.

arounds do occur.

We identified less than a dozen reports.

However, I suspect this has happened a lot more often,

However, I suspect this has happened a lot more often,

because crews usually detect and correct this problem quickly.

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.

It's hard to miss.

It's hard to miss.

It is clearly enunciated

at the top of the primary flight display,

at the top of the primary flight display,

right in the pilot's vision.

And they should have seen that.

So we needed to see what was going

So we needed to see what was going

on in the cockpit at that time.

Whoa.

OK.

Giant 3591.

Giant 3591.

Giant 3591.

Investigators returned to Atlas 3591 data...

Investigators returned to Atlas 3591 data...

This is where go around mode engages.

Autopilot is on.

Autopilot is on.

...to learn what the pilots were

doing when they failed to notice the plane was

in go around mode.

in go around mode.

The plane's engines put out more power.

The plane pitches up.

But look at that.

But look at that.

It pitches up for a bit, and then suddenly down.

It pitches up for a bit, and then suddenly down.

The only way for the plane to pitch down during a go

around would be for the pilot to override the automation.

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,

If he didn't realize that the go around mode was activated,

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

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

Investigators make a key discovery.

Investigators make a key discovery.

Flying through thick clouds with no visual reference

of the horizon, First Officer Aska

of the horizon, First Officer Aska

experienced spatial disorientation.

Once the go around mode was activated,

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,

And, of course, they were in the clouds,

so he couldn't see the horizon.

That effect gave the first officer the feeling

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.

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?

So what's the captain doing?

Now, wouldn't he be looking at the instruments?

He's on the radio with air traffic control.

Giant 3591, in about another 18 miles

we'll cut you due north for a base leg.

we'll cut you due north for a base leg.

Sounds good.

Giant 3591.

OK.

OK.

So when he was finished talking to ATC,

surely he would look at the instruments.

Investigators can't tell where the captain

Investigators can't tell where the captain

was looking at the time.

But the flight data can reveal what he was doing.

Let's see what the elevators tell us.

The elevator data reflects how the pilots

The elevator data reflects how the pilots

handled their control columns to alter

the pitch of the aircraft.

the pitch of the aircraft.

They're working in tandem until the go around mode

is activated.

is activated.

OK, look.

Only the captain's starts moving up.

The captain must have noticed that the plane

The captain must have noticed that the plane

was nose down and pulled up.

By the time he realized what was going on,

By the time he realized what was going on,

their fate was sealed.

Investigators discover the captain tried to pull

the plane out of the dive while First Officer

the plane out of the dive while First Officer

Aska continued to push forward.

Captain!

What's going on?

What's going on?

The airplane was pointed straight down.

And at the last minute, they both were pulling back

trying to save the airplane.

trying to save the airplane.

But it was too low and too late.

During training, it is drilled into the pilots

During training, it is drilled into the pilots

to rely on their instruments and not on their senses.

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.

Pull up!

We got the training records from Atlas.

Check this out.

The team looks into the first officer's training

The team looks into the first officer's training

at Atlas Airlines to understand why

he didn't rely on his instruments

he didn't rely on his instruments

as he was trained to do.

In 2017, the first officer had difficulty

In 2017, the first officer had difficulty

completing normal procedures, thinking

ahead, even troubleshooting.

ahead, even troubleshooting.

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

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

The first officer failed his initial oral examination

The first officer failed his initial oral examination

for the 767 type reading.

He then had difficulty during the flight training portion,

He then had difficulty during the flight training portion,

and he had to receive some remedial training before he

passed the check ride.

passed the check ride.

The remedial training instructor felt the first officer

had a confidence problem.

No.

I'll pick something up.

I just may be a little late.

That's all.

That's all.

After seeing First Officer Aska's dismal training

record with Atlas, the team digs further into his career.

record with Atlas, the team digs further into his career.

Now we need to go back and look

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?

How far back do these go?

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

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

Commute Air.

Trans States.

Mesa.

How many airlines?

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.

and some interesting information in his training.

Air speed, low.

Wait. Wait.

Wait. Wait.

Wait.

Give me a second.

Um...

Wow.

Wow.

This is unbelievable.

Commute Air, incomplete training.

Commute Air, incomplete training.

It's the same story at Air Wisconsin.

He resigns from both.

Investigators looking into the crash of Atlas 3591

Investigators looking into the crash of Atlas 3591

discover a troubling work record for First Officer Aska.

discover a troubling work record for First Officer Aska.

Both those airlines, he actually failed to complete

the first officer training.

the first officer training.

2014, he fails the oral exam, line check, and the check ride.

2014, he fails the oral exam, line check, and the check ride.

In 2017, at Mesa Airlines, Aska trains to upgrade

to the rank of captain.

Approaching minimums.

Approaching decision height.

Approaching decision height.

Minimums.

What?

What?

That's not right.

This first officer

really struggled to pass training to upgrade to captain.

really struggled to pass training to upgrade to captain.

Bloody hell.

What's wrong with this plane?

What's wrong with this plane?

His trainer said that he

had low situational awareness.

He would get flustered, would get frantic.

He would get flustered, would get frantic.

When unusual situations would come about,

he would just press random buttons.

The upgrade is unsuccessful, so he quits.

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

How does such a lousy pilot get a job

flying for one of the biggest cargo delivery

services on the planet?

services on the planet?

He had multiple episodes of poor performance,

failed check rides, serious training deficiencies.

failed check rides, serious training deficiencies.

So we went to Atlas Air and asked, what did you guys know.

So we went to Atlas Air and asked, what did you guys know.

Finally, a CV and his Atlas Air job application.

Finally, a CV and his Atlas Air job application.

Why would Atlas Airlines hire

a pilot with such poor skills?

a pilot with such poor skills?

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

Commute Air 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

There's nothing on this application

about his unsuccessful upgrade attempt at Mesa

or the failed line check at Trans States.

or the failed line check at Trans States.

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

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

we found out that he had failed to disclose

his history at other airlines.

Wait.

Wait. Give me a second.

Um...

Um...

Pilots are expected

to provide their training background and job history,

the same way that non-pilots are expected to provide all

the same way that non-pilots are expected to provide all

of their employment history.

of their employment history.

However, Aska did not include particularly

troublesome training background, and this

troublesome training background, and this

misled future employers.

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

How did this pilot manage to continue slipping

through these cracks, retrain, move on, slip

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.

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

The airplane enters the clouds.

The airplane enters the clouds.

It experiences turbulence.

The first officer's left wrist bumps the go around switches.

The first officer's left wrist bumps the go around switches.

The airplane transitions to go around mode.

The airplane transitions to go around mode.

Whoa.

From the point that the go around mode was activated,

you had the first officer feeling

you had the first officer feeling

the spacial disorientation, not watching his instrumentations,

reacting inappropriately.

reacting inappropriately.

Where's my speed?

Counteracting the autopilot, he pushes

Counteracting the autopilot, he pushes

forward on the control column.

The airplane begins to enter a dive and accelerate further.

The airplane begins to enter a dive and accelerate further.

My speed?

We're stalling.

We're stalling.

Stall!

He's way behind the airplane.

His situational awareness is very, very low.

His situational awareness is very, very low.

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

Captain!

Captain!

What's going on?

By the time the captain realized what was going on

and attempted to correct this by pulling back on the yoke,

and attempted to correct this by pulling back on the yoke,

it was too late.

Lord, have mercy.

Lord, have mercy.

Pull up!

I take these accidents personally.

You know, I want to try and prevent 'em

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.

I want this to not happen again.

And, for me, this accident was so preventable.

And, for me, this accident was so preventable.

In their final report, the NTSB

issues a safety alert about the close proximity of the speed

issues a safety alert about the close proximity of the speed

brake lever to the left go around switch,

which could inadvertently cause an activation.

which could inadvertently cause an activation.

The Board also supports the implementation of a Pilots

Records Database, to allow airlines to access

Records Database, to allow airlines to access

an applicant's employment and training records,

which the FAA was rolling out at the time of the accident.

which the FAA was rolling out at the time of the accident.

The NTSB has advocated for the implementation of the Pilot

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

pilots with repeated performance problems that never made it

into the record keeping system.

The way to improve that issue is to improve

The way to improve that issue is to improve

the record keeping system.