Original subtitles

Want to go east?

We'll go on the west side.

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

What's going on?

Lord have mercy upon myself.

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

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 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 it's possible lord have mercy

37-year-old First Officer Conrad Asker has been a professional pilot 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.

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

The number of warnings proves overwhelming.

Wait, wait. Give me a second.

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.

Okay, Conrad, I'm going to reset to 35,000. Let's try this again.

Two years later, while working for Trans States Airlines, First Officer Asker

fails a check ride, an oral exam, and a line check on the umbrella jet he

did react very severely to minor disturbances basic stuff

pilot 101 instrument type of errors

three

years later after failing captain training at mesa airlines asker's career

is now in jeopardy

Atlas Flight 3591 cruises over the Gulf of Mexico.

Speed 250.

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.

First Officer Conrad Asker is at the controls.

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

Roger, 6,000.

The pilots are flying a Boeing 767-375.

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 enters service as a freighter.

The 767 serves a lot of markets very well.

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.

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.

279 miles from their destination, the pilots set a target altitude for

descent.

Attention all aircraft.

Hazardous information, Houston Center.

Here's a weather advisory.

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

Giant 3591.

Copy that.

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

Oh, 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.

Giant 3591, Houston Center.

There's a light to heavy precipitation west of Dayton moving eastbound.

A few minutes later, the controller updates the crew.

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 want to 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.

The first officer hands control to the captain while he considers his route

around the precipitation.

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.

Want to go east?

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

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.

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.

Captain Blakely sets the new target altitude.

3,000.

The autopilot begins descent earlier to reach the target altitude.

To slow the plane, the first officer deploys the speed brakes.

It actually puts an airfoil 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.

As the plane continues towards Houston, 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 got it back.

Now it's back.

Hey, press the button, it fixes everything.

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 brings it back to your own side of the

aircraft. All right.

Your controls.

My controls.

The captain hands control back to First Officer Asker.

Okay.

Flaps one.

Forty miles from the airport, the crew configures the plane for landing.

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.

Supposed to be unheading, yeah?

As Flight 3591 gets closer to the airport, the pilots prepare for their

final approach.

Giant 3591 in about another 18 miles.

We'll cut you due north for a pace leg.

It's real clear on the other side of this weather, so there should be no

problem getting to the airport.

The controller informs the crew that he'll direct the plane north after they

divert around the weather.

Okay, join 3591.

Where's my speed?

My speed?

We're stalling.

Stall!

What's going on?

Lord have mercy upon myself.

Lord have mercy! Captain!

Pull up!

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.

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.

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.

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.

NTSB investigator David Lawrence joins the team.

He has worked on more than 300 air accidents.

Split into a million pieces.

I 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.

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.

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 going to recover the flight recorders.

I pulled the data on Atlas 3591 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.

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

control instructions air traffic had with the accident flight.

Looks like it could get bumpy in there.

Did the crew mention lightning or if they were struggling?

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 distressed ankles?

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.

There was no Mayday call?

Their communications were standard and normal, 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.

See?

Here. The altitude dropped quickly.

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.

With weather eliminated as a reason for the crash... Maybe it's a flight control

problem.

Investigators turn to the wreckage for clues.

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

A jack screw inside the tail controls the horizontal stabilizer.

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.

11.25 inches.

Nothing unusual here.

The position of 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.

With a runaway stabilizer ruled out, investigators returned to the plane's

descent.

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

Could the sudden loss of altitude have been deliberate?

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

It's possible.

In the past, pilots have purposefully crashed the airplane due to

psychological problems.

In 2015,

The first officer on a German wings 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 Lamb 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.

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.

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.

What about the first officer?

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.

Good timing.

Thanks.

The cockpit voice recording should shed light on why Atlas 3591 was in a high

-speed descent.

They're discussing target altitude.

Pretty standard stuff.

I don't detect any stress in their voices.

None.

Fast forward a little bit.

Alright, thanks for the heads up.

Giant 3591.

How do you want to 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.

As investigators listen to the crew and air traffic control discuss the flight

path around the weather, they hear something interesting.

Okay, I got it back.

Now it's back.

Hey, press the button, it fixes everything.

Some of the instrument displays must have gone blank.

And they got them back right away.

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.

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.

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?

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.

Fifteen seconds later, they crash.

While investigators await flight data, they review the intriguing

lead from the plane's cockpit voice recording.

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?

What's going on?

Okay.

Let's assume it stalled.

How come?

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

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 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

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 the 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.

Looks like every pallet was well secured.

And locking and loading was double checked

Center of gravity and specs look impeccable

Look

at this 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.

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

The first time I saw the security video, it was really disturbing because 767s

just don't fly straight down like that.

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

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 is trying to recover from one.

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.

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.

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

From the plane's configuration, investigators determined that Atlas 3591

could have been trying to recover from a stall.

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

Captain!

What's going on?

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

too late and the aircraft impacted the swamp.

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

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

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

The pitch is normal. The plane speed is consistent at 275 knots.

Everything looks fine to this point. Let's just move ahead to the...

final minute of flight whoa

okay something goes wrong right here

that's 32 seconds before the crash yeah where exactly does the first officer say

the plane is stalling

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 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.

The Boeing 767 has very good stall characteristics.

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 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. When the first officer yelled out that the airplane was

stalling... Stall! The airplane was nowhere near stalling.

Atlas 3591... Pull up!

...crashed for another reason.

Check this out.

The plane went into go-around mode.

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.

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.

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.

Using Atlas 3591's flight data.

Investigators recreate the pilot's actions up to the moment when the go

-around mode is activated.

The plane is descending normally.

The autopilot and autothrottle 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.

When you extend the speed brake in the 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.

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.

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.

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 as flight

3591 gets closer to the airport the pilots prepare for their final approach

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

Sounds good. John 3591.

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 pilot's reports.

Investigators discover that inadvertent go-arounds do occur.

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.

It's hard to miss.

It is clearly enunciated 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 on in the cockpit at that time.

Whoa.

Okay. Giant 3591.

Investigators return to Atlas 3591's data.

This is where go-around mode engages.

Autopilot is on.

To learn what the pilots were doing when they failed to notice the plane was in

go-around mode.

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.

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.

Investigators make a key discovery.

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

Officer Asker experienced spatial disorientation.

Once the go-round 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.

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

Sounds good, China 3591.

Okay, so when he was finished talking to ATC, surely he would look at the

instruments.

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.

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.

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.

Investigators discover the captain tried to pull the plane out of the dive.

while First Officer Asker continued to push forward.

Captain, 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, 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?

I would have mercy upon myself.

We got the training records from Atlas.

Check this out.

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 checkride on the 767, too.

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 checkride.

The remedial training instructor felt the first officer had a confidence

problem.

After seeing First Officer Asker'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.

Commute air, trans-states, Mesa. How many airlines?

Six other airlines over nine years.

So as we look back into the history of this pilot, we started to find some

interesting gaps and some interesting information in his training.

Air C, hello.

Wait, wait, wait.

Give me a second.

Wow,

this is unbelievable.

Commute air.

Incomplete training.

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

Investigators looking into the crash of Atlas 3591 discover a troubling work

record for First Officer Asker.

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

training.

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

In 2017 at Mesa Airlines, ask a train to upgrade to the rank of captain.

Approaching minimums. Approaching decision height.

Minimums. What?

That's not right.

This first officer really struggled to pass training to upgrade to captain.

Bloody hell.

What's wrong with this plane?

His trainer 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.

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?

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.

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

Commute Air and Air Wisconsin aren't even on a 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.

Wait, give me a second.

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, ASCA 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.

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.

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?

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.

He's way behind the airplane. His situational awareness is very, very low.

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

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, it was too late.

Lord have mercy.

Pull up!

I take these accidents

personally. I want to try and prevent them 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.

In their final report, the NTSB 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.

The board also recommends the implementation of a pilot's 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.

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.