Aircraft Accidents and Lessons Unlearned XXIII: Atlas Air 3591

On February 23, 2019, at 12:45 PM Central time, Atlas Air flight 3591, a Boeing 767-375ER, accident number DCA19MA086, crashed in Trinity Bay outside Houston, Texas. All three persons aboard were fatally injured. That’s it. There is nothing else to report; there is nothing else known.

Yet, even in the early stages of this investigation, there are three lessons unlearned from other accidents that we need to adhere to, to remember. The first lesson, often forgotten, whether intentionally or unintentionally, is compassion; that there are real people hurting because of this tragedy. The second lesson is that speculation is bound to take place; make it count. The third lesson is that, although this was a cargo accident, it deserves the attention of any major or minor accident.

Compassion – One thing I learned early on as a major accident investigator for the National Transportation Safety Board (NTSB) was to look beyond the accident to the families who must now be dragged into the spotlight while their family member’s final decisions are scrutinized by everyone from the pilots’ union to local barbershop regulars. When we allow this type of sensationalism, it destroys innocence, invites doubt and heightens grief. And, it diverts attention from evidence important to finding a root cause. I am reminded of the circuses surrounding such tragedies as Malaysia Airlines MH370 or Germanwings 9535, when the media and their experts felt it necessary to be investigators-without-a-clue and providers of false hope. To everyone within range of my written voice: Let this play out folks, with professional patience, and let the families grieve in peace.

Speculation – there are two types of speculation, good and bad. Good speculation occurs when small groups of professionals, e.g. mechanics or pilots, discuss the accident in the privacy of the line shack or ready room; generating a discussion. There may be those familiar with the B767 or any aviation professional who can glean from what is known about the accident and adjust their Routine – that infamous ally of Complacency. Perhaps a pilot will reread their emergency procedures, again; a mechanic will double-check the maintenance manual paperwork or maybe a pre or post-flight walk-around will take a little longer to complete, allowing the flashlight to closely trace the hydraulic lines in the wheel well. Any boost to our awareness is welcome. Feel free to talk amongst yourselves. Please, keep it professional.

When I investigated China Airlines flight CI611 in 2002, the aircraft still rested on the ocean floor when I arrived in Taiwan. There were no recorders to review yet; they hadn’t been recovered. But, the Taiwanese Aviation Safety Council (ASC) investigators and I didn’t wait for the recorders. Instead, we reviewed all the maintenance accomplished on the accident aircraft, going back as far as we could. We did visual inspections of sister B747s in the fleet and the ASC investigators interviewed mechanics and pilots to see if there was anything to focus on. We were proactive; we speculated in a way that saved time and exploited our resources. That’s good speculation.

Then there is bad speculation. Turning on the evening news to find some self-described aviation expert, proudly holding his model of the accident airplane, maybe with the correct paint scheme, as he waits for the cameras to focus on him. We all know the type: he expounds on opinion with little attention to fact; looking sober while struggling to remember that the model’s vertical stabilizer points up in flight. To the point, this speculation is harmful, not only to the truth, but to the distraction it gives to the investigation. As with Malaysia Airlines MH370, how many experts did it take to make the search crews go round in circles as the recorders’ batteries died? As with TWA 800, how many expert theories did the nation have to listen to, from terrorist bombs to missiles, before the investigation moved forward?

The aviation news website, AvWeb, posted an article on February 26, 2019, referencing a report in Business Insider. Several Atlas pilots – seriously, PILOTS – criticized Atlas for high workloads and low pay. Is this type of selfishness really necessary, to make this tragedy about pay and workload? Perhaps selfies will get these pilots some extra attention. Did their complaining point to root cause or were these pilots just wanting facetime? They presented no evidence; speculation was unnecessary. How do union negotiation issues at this tragic time contribute to the investigation?  They don’t.

Houston’s NBC news affiliate, KPRC-Click2News, posted amateur video on its website: four seconds of Atlas 3591 descending, accompanied by an interview with a former NTSB accident investigator, who was spit-balling without evidence, e.g. “Maintenance issues and mechanical malfunctions, while they are rare events, can and do occur.” What information did that statement provide? None. He then made assumptions about cargo airline work hours, saying, “The effects of fatigue can also be acquainted to someone that is drunk because it impairs not only logical thinking, decision-making, but can have motor skill impairment, as well.” This expert’s logic is all over the place. Maintenance issues? Night shifts? Pilots are, “someone that is drunk”? His dizzying ‘expert opinion’ covered everything but oatmeal food poisoning. Did the ‘expert’ ever fly for a cargo airline? I’m asking because he contributed ab-so-lute-ly nothing to the investigation.

The question of cargo airline flight hours has long been hauled into the accident investigation spotlight; pilot unions, former NTSB investigators and uninformed bureaucrats have lamented the unfairness of operating airplanes in the early morning hours, even though these successful overnight flights, number in the millions since the mid-seventies. I have worked in FedEx’s Memphis Superhub and their Newark Metroplex during those allegedly notorious shift hours. I never observed pilots or fellow mechanics walking drunkenly gate-to-gate; sleeping at the controls or crying out, “Oh, the humanity!” In Omaha, I never saw an exhausted pilot do a half gainer off the crew stairs after his two hour morning flight. As an FAA inspector, I spoke with pilots and mechanics from UPS and other cargo airlines; I never met these lethargic individuals, lurching about beside me as we performed the pre-flight walk-around.

And didn’t the accident occur at 12:45 in the afternoon? Are we ignoring the facts; afraid they will get in the way of speculation and tarnishing the accident pilots’ experience and reputation?

Cargo Accident – I investigated Emery 17, accident number DCA00MA026. Of the Board Members at the time, only Member John Goglia took the investigation the full distance, insisting on a proper hearing. The results of that investigation should have had long term results that should have shaken the aviation community to its core, possibly preventing later air disasters. Why? Because cargo accidents happen in the same airplanes, at the same airports and in the same air space used by passenger airlines; they are affected by the same consequences of that industry.

The NTSB needs to take this accident seriously … very seriously. They need to not only determine probable cause, but they must determine root cause. This accident can’t be about the number of people killed, but about how this affects the entire community; how what is found affects everyone’s safety.

Then there is that four-second amateur video. This video is only a tool, nothing more; a video that supports the investigation, not an investigation that supports the video. The NTSB must not make the same mistake that they made with National Air Cargo flight 102’s amateur video. These videos don’t show the accidents; they show what took place after the accident began.

This accident investigation has just begun. Let us all be professional, compassionate, patient and exercise common sense. We, the aviation community, demand it. The families of the deceased? They deserve it.

12 thoughts on “Aircraft Accidents and Lessons Unlearned XXIII: Atlas Air 3591”

  1. Steve, good article, very good point. But in today’s society of instant answers and instant correction it will not be effective.

    1. Thanks Doc, I understand; you’re probably right. However, as an up-and-coming (hopefully) author I can’t always write what people want to hear, but, from my perspective, need to hear. And that especially means people of influence in our industry.

    1. I agree Stephen.
      I never understood why cargo accident with just one or two fatalities and a hole in the ground wasn’t as important as a commercial or air carrier crash. Same hole in the ground. Maybe even the same type airplane. That’s the media today. They almost never follow-up.
      They ignore foreign accidents also.

      1. That’s a good point about international. I am not sure why that is; perhaps skepticism about foreign investigation groups, especially in smaller countries.

        I feel that the less-than-enthusiastic media attention has to do with casualty numbers more than anything else. The interest is even less if the crew survives. I remember Colgan 9446 crashed in the ocean off Yarmouth, MA in 2003; a passenger repositioning flight, Beech 1900D, that killed the two pilots. It barely made page six in the papers, but the root cause was applicable to all Part 121 air carriers. A lost opportunity for the industry to learn.

        Thanks Pete.

  2. Good article Stephen. Maybe accident investigations are not taught with those concerns you point out. During my time as an ASI, I always thought about the families involved, but more importantly, look at the probable causes with any risk analysis to support any findings. Sometimes these accidents are preconceived or solved before completing investigating all the facts. Like the accident you went on involving a DC-9 aircraft that everyone said to say it was the pitch trim actuator when it was the floor that collapsed causing loss of control of the aircraft. Human nature will be what it is until things change in training, training and training.

  3. Thanks for the thoughtful commentary. Too many times the human considerations are brushed aside. Hoping it helps to refocus on the objective, esp for the “experts.”

    1. Mark, Thanks for the reply. I hope we can focus on what’s not only important, but what’s right. I hope you’re enjoying the retirement; I keep count of the days until mine.

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