3 fatal · Boeing 767 · 2019-02-23 · Trinity Bay, TX, USA
Event
NTSB number
DCA19MA086
Event ID
20190223X60222
Type
Accident
Date
2019-02-23
Location
Trinity Bay, TX, USA
Coordinates
29.77, -94.660003
Injuries
Highest injury
FATL
Fatal
3
Serious
0
Minor
0
Uninjured
0
Total aboard
3
Aircraft
Make
Boeing
Model
767
Registration
N1217A
FAR Part
121
Engines
2
Damage
DEST
Conditions
Light
DAYL
Weather
IMC
Probable cause
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.