Boeing 767 accident near Trinity Bay, Texas, February 23, 2019
On February 23, 2019 at about 6:39 pm local time, a 1992 Boeing 767, registered N1217A, was destroyed in an accident during enroute (descent) near Trinity Bay, Texas (George Bush Intercontinental airport). It was flown under scheduled airline rules (Part 121). 3 people were killed. The weather was instrument conditions (cloud, fog or low visibility).
The NTSB's probable cause their words, unchanged
The inappropriate response by the first officer as the pilot flying to an inadvertent activation of the go-around mode, which led to his spatial disorientation and nose-down control inputs that placed the airplane in a steep descent from which the crew did not recover. Contributing to the accident was the captain's failure to adequately monitor the airplane's flightpath and assume positive control of the airplane to effectively intervene. Also contributing were systemic deficiencies in the aviation industry's selection and performance measurement practices, which failed to address the first officer's aptitude-related deficiencies and maladaptive stress response. Also contributing to the accident was the Federal Aviation Administration's failure to implement the pilot records database in a sufficiently robust and timely manner.
Source: NTSB aviation accident database, copy made October 5, 2026. Docket and reports at the NTSB.
What the record shows
- Date
- February 23, 2019 · about 6:39 pm local time
- Place
- Trinity Bay, Texas · George Bush Intercontinental · map
- Type
- Accident
- Injuries
- 3 people were killed.
- Weather
- instrument conditions (cloud, fog or low visibility)
- Aircraft
- Boeing 767 375, built 1992 · all 767s on the register
- Registration
- N1217A · registry record · serial 25865
- Damage
- Destroyed
- Flight
- Flight · scheduled airline rules (Part 121)
The NTSB's narrative final · quoted from the NTSB record
The Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/aviation.aspx. The Aircraft Accident Report number is NTSB/AAR-20/02. On February 23, 2019, at 1239 central standard time, Atlas Air Inc. flight 3591, a Boeing 767-375BCF, N1217A, was destroyed after it rapidly descended from an altitude of about 6,000 ft mean sea level and crashed into a shallow, muddy marsh area of Trinity Bay, Texas, about 41 miles east-southeast of George Bush Intercontinental/Houston Airport (IAH), Houston, Texas. The captain, first officer, and a nonrevenue pilot riding in the jumpseat died. Atlas operated the airplane as a Title 14 Code of Federal Regulations Part 121 domestic cargo flight for Amazon.com Services LLC, and an instrument flight rules flight plan was filed. The flight departed from Miami International Airport, Miami, Florida, about 1033 (1133 eastern standard time) and was destined for IAH.
The complete narrative as the NTSB published it. The NTSB's docket holds the report as a PDF and any photographs, statements and other documents from the investigation.
The factual record from the NTSB's investigation tables, in plain English
What happened, in order
- Loss of control in flight during enroute (descent) defining event
The NTSB's findings
- factor Organizational issues › Support/oversight/monitoring › Documentation/record keeping › Personnel records › Not specified
- factor Organizational issues › Support/oversight/monitoring › Documentation/record keeping › Personnel records › FAA/Regulator
- Aircraft › Aircraft systems › Auto flight system › (general) › Unintentional use/operation
- Personnel issues › Experience/knowledge › Experience/qualifications › Qualification/certification › Copilot
- Personnel issues › Psychological › Perception/orientation/illusion › (general) › Copilot
- Personnel issues › Experience/knowledge › (general) › (general) › Copilot
- Personnel issues › Psychological › Attention/monitoring › Attention › Pilot
- Personnel issues › Psychological › Personality/attitude › Personality › Copilot
- Personnel issues › Task performance › Use of equip/info › Use of automation › Copilot
- Personnel issues › Action/decision › Action › Incorrect action performance › Copilot
- Aircraft › Aircraft systems › Indicating/recording systems › Data recorders (flight/maint) › Design
- Aircraft › Aircraft systems › Auto flight system › (general) › Design
Pilot
- Certificate: airline transport pilot, flight instructor
- Ratings: multi-engine land; single-engine land; instructor: airplane multi-engine; instructor: airplane single-engine; instructor: instrument airplane; instrument: airplane
- Flight time: 11,172 hours in all; 1,252 in this make and model; 100 in the last 90 days; 34 in the last 30 days; 4,235 as pilot in command
- Medical certificate: Class 1 (with waivers/limitations)
- Seat: left
- Injury: fatal
Co-pilot
- Certificate: airline transport pilot
- Ratings: multi-engine land; single-engine land
- Flight time: 5,073 hours in all; 520 in this make and model; 106 in the last 90 days; 34 in the last 30 days; 1,237 as pilot in command
- Medical certificate: Class 1 (with waivers/limitations)
- Seat: rgt
- Injury: fatal
Pilot-Rated Passenger
- Certificate: airline transport pilot, flight instructor
- Ratings: multi-engine land; single-engine land; instructor: airplane single-engine
- Medical certificate: Class 1 (without waivers/limitations)
- Seat: unk
- Injury: fatal
The aircraft
- Maximum gross weight: 400,998 lb
- Landing gear: fixed
- Engine 1: General Electric CF6-80C2B6F (turbofan); 0 hours total
- Engine 2: General Electric CF6-80C2B6F (turbofan); 0 hours total
- Operator: Atlas Air
The flight
- Departed from: KMIA Miami at 4:00 pm
- Destination: KIAH Houston TX
- Flight plan: IFR
- A second pilot was aboard
Weather at the time
- Light: daylight
- Temperature: 0°F (-18°C), dew point 0°F (-18°C)
- Observation at 12:35 pm from KIAH, 41 miles away
Injuries
| Fatal | Serious | Minor | None | |
|---|---|---|---|---|
| Flight crew | 2 | |||
| Passengers | 1 |
Documents from the investigation the NTSB's docket: the evidence folder behind the report
78 documents, released by the NTSB on December 19, 2019. View them here, or download them; the NTSB redacts some personal details before release, and this site shows the NTSB's own titles rather than its file names.
The same docket at the NTSB · documents without a copy here are fetched from the NTSB when you open them.
Other NTSB records under N1217A the same tail number, which may have belonged to a different aircraft at the time
Everything on this page comes from the NTSB's public records. The narrative, probable cause and findings are the NTSB's own words; the coded tables behind the report are written out in plain English, with pilots' ages, home towns and medical details left out. The documents and photographs are the NTSB's docket, shown as the NTSB released them. This site's own text never names anyone involved. A preliminary report can change; the final report usually follows one to two years later, and the page is refreshed when it does.