Investigation Summary
The accident occurred as the flight was descending through approximately 6,300 feet toward a target altitude of 3,000 feet. As the aircraft began to penetrate the leading edge of a cold front, it encountered associated windshear and light turbulence. During this encounter, the first officer likely bumped the go-around (GA) switch with his left wrist or watch while manipulating the speedbrake lever. This caused the autothrottle to increase engine thrust and the autopilot to command a nose-up pitch. Because the crew was focused on navigating weather and programming the FMC, they did not immediately notice the mode change. The sudden acceleration triggered a somatogravic illusion in the first officer, a sensory deception where the body perceives forward acceleration as a steep climb. Despite no stall warnings, the first officer shouted that the plane was stalling and pushed the nose down aggressively. The captain, distracted by radio communications and FMC entries, did not take positive control until the aircraft was in a 49 degree dive, by which time recovery was impossible.
Final Conclusions
The NTSB determined the probable cause was the first officer's inappropriate response to the inadvertent activation of go-around mode, leading to spatial disorientation and nose-down control inputs. Contributing factors included the captain's failure to monitor the flightpath and intervene, systemic deficiencies in pilot selection that failed to identify the first officer's history of training failures and maladaptive stress response, and the FAA's delay in implementing a robust pilot records database.
Photographic Evidence (1)
Video Analysis
Deadly Deception! Unraveling the Mystery of Atlas Air Flight 3591. — A detailed breakdown of the spatial disorientation and training failures that led to the crash of a Boeing 767 freighter into Trinity Bay.
If playback is blocked, the owner has disabled embedding — use the link above.
Airframe & Maintenance
Crew Experience
Captain
Placed in Pilot Proficiency Watch Program (PWP) after 2015 training failures including exceeding flap limits during stall recovery, forgetting to set missed approach altitude, and general difficulties with missed approaches.
First Officer
Had a history of training failures and remediation at multiple previous employers, which he concealed during hiring. Examiner described him as stressed and lacking situational awareness during checkrides.
Systems & Failure Modes
Go-Around (GA) Mode
A flight director/autopilot mode that commands maximum thrust and a specific pitch-up attitude for missed approaches; its inadvertent activation at 6,000 feet triggered the accident sequence.
Autothrottle
Automatically increased engine thrust to go-around levels, providing the longitudinal acceleration that induced the first officer's somatogravic illusion.
Pilot Records Database (PRD)
An FAA system intended to share pilot training and performance history between carriers; its lack of robustness was cited as a contributing factor.
Interesting Facts
- 01The first officer had a history of training failures at multiple airlines which he had concealed from Atlas Air.
- 02The somatogravic illusion caused the first officer to perceive a pitch-up sensation that did not exist.
- 03The aircraft reached a nose-down pitch of approximately 49 degrees during the descent.
- 04No mechanical failures were found; the aircraft responded correctly to all control inputs.
- 05The FAA Pilot Records Database (PRD) was not fully implemented at the time, allowing the first officer's record to remain hidden.
Safety Actions & Advisories
Pilot Records Database Implementation
Source ↗The NTSB reiterated the need for the FAA to fully implement a robust pilot records database to ensure airlines can access a pilot's complete training history, including failures.
767/757 Go-Around Training
Recommended that Boeing 767 and 757 operators provide specific training for crews to recognize and recover from inadvertent go-around mode activation.