Last week, the NTSB held a 4-hour meeting about the crash of an Atlas Air 767 that crashed into a Bay near Houston last year. Amazingly everything was going fine until both pilots started making errors, and in just 30 seconds they plunged from 6,000 feet into the Bay. In episode #156 of my Aviation News Talk podcast, I played clips from the meeting most relevant for General Aviation Pilots, and at the end I gave five takeaways that all GA pilots can learn from this accident. I've just posted a YouTube version of that episode, which lets you see the graphics shown during presentations at the NTSB Board meeting, and you can see the Board members as they pose questions to the NTSB staff. Here's a brief overview.

On February 23rd, 2019 at 1239 CDT, Atlas Air flight 3591, a Boeing 767-375 converted freighter, N1217A, entered a rapid descent from about 6,300 feet and impacted a marshy area about 41 miles Southeast of the George Bush Intercontinental airport in Houston, Texas. The two pilots and one non-revenue seat pilot were fatally injured.

The airplane was destroyed and highly fragmented. The airplane was on a scheduled flight from Miami, Florida to Houston. And as the airplane approached the Southeast coast of Texas, there was a small area of convective weather along the route of flight. The First Officer was the pilot flying, and the crew discussed a deviation around the weather to the West. During the same timeframe, the First Officer had a display issue of some kind and temporarily transferred control to the Captain, until he cleared the problem using the EFI or Effie switch, which selects source information for the electronic displays. The airplane was on a westerly vector around the weather, and ATC instructed the crew to expedite decent due to departure traffic.

At 12:38, the airplane was descending on autopilot with speed brakes extended, to assist in expediting the descent to 3000 feet. Standard procedures recommend the pilot flying should be guarding the speed brake handle to prepare for retraction at level off. This positions the First Officer's arm in close proximity to the go around switch, mounted on the left thrust lever. The NTSB believes that during the descent, as the aircraft hit turbulence, the First Officer inadvertently hit the go around switch. Normally, this mistake would be benign, and the pilots would correct the error. However, in this case, both pilots failed to follow standard operating procedures, and both were operating their controls--while the autopilot was still on--and their actions led to the loss of the aircraft.

A significant factor was somatogravic illusion, which occurs whenever a person is accelerated, which led the pilots to feel as if they were in a nearly straight up climb, when in fact they were almost level. I'll be talking more about somatogravic illusion in a future episode.

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