# NTSB DCA19MA086: Boeing 767, N1217A, Trinity Bay, TX, February 23, 2019

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Class 1 · Major · Final report
- Date: February 23, 2019, 12:39 local (18:39 UTC)
- Place: Trinity Bay, TX
- Coordinates: 29.77, -94.660003 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=29.7700&lon=-94.6600&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Defining event: [Enroute-descent: Loss of control in flight](https://openairdocs.org/ntsb-events/240)
- Highest injury: Fatal
- Injuries: 3 fatal
- Status: Completed, report August 4, 2020
- Report: Board-adopted at Board Meeting
- Investigation class: Class 1
- NTSB office: Major Investigations Division
- Safety recommendations: Yes
- NTSB case key (mKey): 99013
- NTSB case page: https://www.ntsb.gov/investigations/Pages/DCA19MA086.aspx
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99013/pdf
- Board report AAR2002 (PDF): https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR2002.pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99013
- Page: https://openairdocs.org/ntsb/DCA19MA086

## 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.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Documentation/record keeping: personnel records](https://openairdocs.org/ntsb-findings/04033015): Organizational issues › Support/oversight/monitoring · Not specified (probable cause); cases with it: [Boeing 767-375, 1 case](https://openairdocs.org/ntsb-findings/04033015/cases.md?model=1385217), [All aircraft, 6 cases](https://openairdocs.org/ntsb-findings/04033015/cases.md)
- [Documentation/record keeping: personnel records](https://openairdocs.org/ntsb-findings/04033015): Organizational issues › Support/oversight/monitoring · FAA/Regulator (probable cause); cases with it: [Boeing 767-375, 1 case](https://openairdocs.org/ntsb-findings/04033015/cases.md?model=1385217), [All aircraft, 6 cases](https://openairdocs.org/ntsb-findings/04033015/cases.md)
- [Auto flight system](https://openairdocs.org/ntsb-findings/01022200): Aircraft › Aircraft systems · Unintentional use/operation (probable cause); cases with it: [Boeing 767-375, 1 case](https://openairdocs.org/ntsb-findings/01022200/cases.md?model=1385217), [All aircraft, 8 cases](https://openairdocs.org/ntsb-findings/01022200/cases.md)
- [Experience/qualifications: qualification/certification](https://openairdocs.org/ntsb-findings/02031010): Personnel issues › Experience/knowledge · Copilot; cases with it: [Boeing 767-375, 1 case](https://openairdocs.org/ntsb-findings/02031010/cases.md?model=1385217), [All aircraft, 280 cases](https://openairdocs.org/ntsb-findings/02031010/cases.md)
- [Perception/orientation/illusion](https://openairdocs.org/ntsb-findings/02022000): Personnel issues › Psychological · Copilot; cases with it: [Boeing 767-375, 1 case](https://openairdocs.org/ntsb-findings/02022000/cases.md?model=1385217), [All aircraft, 8 cases](https://openairdocs.org/ntsb-findings/02022000/cases.md)
- [Personnel issues](https://openairdocs.org/ntsb-findings/02030000): Personnel issues › Experience/knowledge · Copilot; cases with it: [Boeing 767-375, 1 case](https://openairdocs.org/ntsb-findings/02030000/cases.md?model=1385217), [All aircraft, 10 cases](https://openairdocs.org/ntsb-findings/02030000/cases.md)
- [Attention/monitoring: attention](https://openairdocs.org/ntsb-findings/02021510): Personnel issues › Psychological · Pilot; cases with it: [Boeing 767-375, 1 case](https://openairdocs.org/ntsb-findings/02021510/cases.md?model=1385217), [All aircraft, 226 cases](https://openairdocs.org/ntsb-findings/02021510/cases.md)
- [Personality/attitude: personality](https://openairdocs.org/ntsb-findings/02021030): Personnel issues › Psychological · Copilot; cases with it: [Boeing 767-375, 1 case](https://openairdocs.org/ntsb-findings/02021030/cases.md?model=1385217), [All aircraft, 8 cases](https://openairdocs.org/ntsb-findings/02021030/cases.md)
- [Use of equip/info: use of automation](https://openairdocs.org/ntsb-findings/02063010): Personnel issues › Task performance · Copilot (probable cause); cases with it: [Boeing 767-375, 1 case](https://openairdocs.org/ntsb-findings/02063010/cases.md?model=1385217), [All aircraft, 17 cases](https://openairdocs.org/ntsb-findings/02063010/cases.md)
- [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Copilot (probable cause); cases with it: [Boeing 767-375, 1 case](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=1385217), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md)
- [Indicating/recording systems: data recorders (flight/maint)](https://openairdocs.org/ntsb-findings/01023130): Aircraft › Aircraft systems · Design; cases with it: [Boeing 767-375, 1 case](https://openairdocs.org/ntsb-findings/01023130/cases.md?model=1385217), [All aircraft, 17 cases](https://openairdocs.org/ntsb-findings/01023130/cases.md)
- [Auto flight system](https://openairdocs.org/ntsb-findings/01022200): Aircraft › Aircraft systems · Design; cases with it: [Boeing 767-375, 1 case](https://openairdocs.org/ntsb-findings/01022200/cases.md?model=1385217), [All aircraft, 8 cases](https://openairdocs.org/ntsb-findings/01022200/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Enroute-descent: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Boeing 767-375, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=1385217), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md)

## Analysis

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.

## Factual narrative

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.

## Aircraft

- Registration: [N1217A](https://openairdocs.org/aircraft/N1217A), registered now, S/N 25865, built 1992 (OpenAirDocs)
- Reported make and model: Boeing 767 (375)
- Registry model: [Boeing 767-375](https://openairdocs.org/model/boeing-767-375) (registry code 1385217) (OpenAirDocs)
- Registry engine: [GE CF6-80C2B6F](https://openairdocs.org/engine/ge-cf6-80c2b6f) (registry code 30109, turbo-fan) (OpenAirDocs)
- Category: Airplane
- Serial number: 25865
- Year built: 1992
- Engines: General Electric CF6-80C2B6F 24995 horsepower turbo fan; General Electric CF6-80C2B6F 24995 horsepower turbo fan
- Damage: Destroyed
- Flight: Part 121
- Operator: Atlas Air
- Registered owner: Andromeda Leasing I Llc
- Airworthiness certificate: Standard, Transport
- Departed: KMIA, Miami
- Destination: KIAH, Houston, TX
- Flight plan: IFR
- Airport: KIAH, George Bush Intercontinental

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 60; injuries: fatal; airline transport, flight instructor; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; seat: left; flight hours: 11,172 total, 1,252 in this make and model, 4,235 as pilot in command, 100 in the last 90 days, 34 in the last 30 days, 2.4 in the last 24 hours
- Co-pilot; age 44; injuries: fatal; airline transport; airplane ratings: single-engine land, multi-engine land; medical: class 1, with waivers/limitations; seat: right; toxicology performed; flight hours: 5,073 total, 520 in this make and model, 1,237 as pilot in command, 106 in the last 90 days, 34 in the last 30 days, 2.4 in the last 24 hours
- Pilot-rated passenger; injuries: fatal; airline transport, flight instructor; airplane ratings: single-engine land, multi-engine land; medical: class 1, without waivers/limitations; toxicology performed

## Weather

- Conditions: Instrument (IMC), Day
- Observed at: KIAH, 41 nm away

## FAA reports on this event (1)

The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs).

- [Accident 20190223013239A](https://openairdocs.org/incident/20190223013239A), Feb 23, 2019: Boeing 767-375, Anahuac, TX, Destroyed, 3 fatal. Saturday, February 23, 2019, at approximately 12:39PM CST, a Boeing 767-300ER airplane, operated by atlas Airlines (for amazon prime air) as giant flight 3591,…

## Docket (78 files)

The files NTSB released with the investigation on December 19, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99013. 1.5 GB in all.

- Operations group chairman's factual report (item 1, PDF, 86 pages, 3.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8858931&FileExtension=pdf&FileName=DCA19MA086%20-%20Ops_HP%20Factual%20(FINAL)%20ver%207.0%20(Tech%20Review%20ready)-Rel.pdf
- Operations attachment 1 - atlas air interview transcripts (item 2, PDF, 734 pages, 2.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8720530&FileExtension=pdf&FileName=DCA19MA086%20Attachment%201%20-%20Atlas%20Air%20Interview%20Transcripts%20(FINAL)_Redacted-Rel.pdf
- Operations attachment 2 - records of conversation (item 3, PDF, 12 pages, 230 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8720263&FileExtension=pdf&FileName=DCA19MA086%20Attachment%202%20-%20Records%20of%20Conversation%20(FINAL)-Rel.pdf
- Operations attachment 3 - atlas air flight 3591 flight release (item 4, PDF, 39 pages, 946 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8856871&FileExtension=pdf&FileName=DCA19MA086%20Attachment%203%20-%20Atlas%20Air%20Flight%203591%20Flight%20Release%20(FINAL)_Redacted-Rel.pdf
- Operations attachment 4 - weight and balance information (item 5, PDF, 19 pages, 7.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8720539&FileExtension=pdf&FileName=DCA19MA086%20Attachment%204%20-%20Weight%20and%20Balance%20Information%20(FINAL)_Redacted-Rel.pdf
- Operations attachment 5 - atlas air 3591 cargo loader information (item 6, PDF, 32 pages, 7.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8720629&FileExtension=pdf&FileName=DCA19MA086%20Attachment%205%20-%20Atlas%20Air%203591%20Cargo%20Loader%20Information%20(FINAL)_Redacted-Rel.pdf
- Operations attachment 6 - stratair employee statements (item 7, PDF, 27 pages, 12.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8720814&FileExtension=pdf&FileName=DCA19MA086%20Attachment%206%20-%20Stratair%20Employee%20Statements%20(FINAL)_Redacted-Rel.pdf
- Operations attachment 7 - national airport services (nas) employee statements (item 8, PDF, 32 pages, 329 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8720730&FileExtension=pdf&FileName=DCA19MA086%20Attachment%207%20-%20National%20Airport%20Services%20(NAS)%20Employee%20Statements%20(FINAL)_Redacted-Rel.pdf
- Operations attachment 8 - atlas air flight 3591 acars messages (item 9, PDF, 43 pages, 123 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8719102&FileExtension=pdf&FileName=DCA19MA086%20Attachment%208%20-%20%20Atlas%20Air%20Flight%203591%20ACARS%20Messages%20(FINAL)_Redacted-Rel.pdf
- Operations attachment 9 - captain information (item 10, PDF, 4 pages, 10.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8720353&FileExtension=pdf&FileName=DCA19MA086%20Attachment%209%20-%20Captain%20Information%20(FINAL)_Redacted-Rel.pdf
- Operations attachment 10 - first officer information (item 11, PDF, 4 pages, 3.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8720739&FileExtension=pdf&FileName=DCA19MA086%20Attachment%2010%20-%20First%20Officer%20Information%20(FINAL)_Redacted-Rel.pdf
- Operations attachment 11 - atlas training records - captain (item 12, PDF, 131 pages, 26.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8720548&FileExtension=pdf&FileName=DCA19MA086%20Attachment%2011%20-%20Atlas%20Training%20Records%20-%20Captain%20(FINAL)_Redacted-Rel.pdf
- Operations attachment 12 - atlas training records - first officer (item 13, PDF, 70 pages, 41.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8722006&FileExtension=pdf&FileName=DCA19MA086%20Attachment%2012%20-%20Atlas%20Training%20Records%20-%20First%20Officer%20(FINAL)_Redacted-Rel.pdf
- Operations attachment 13 - crew schedules (item 14, PDF, 23 pages, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8858718&FileExtension=pdf&FileName=DCA19MA086%20Attachment%2013%20-%20Crew%20Schedules%20(FINAL)_Redacted-Rel.pdf
- Operations attachment 14 - captain pria documentation (item 15, PDF, 21 pages, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8722521&FileExtension=pdf&FileName=DCA19MA086%20Attachment%2014%20%20-%20Captain%20PRIA%20Documentation%20(FINAL)_Redacted-Rel.pdf
- Operations attachment 15 - first officer pria documentation (item 16, PDF, 50 pages, 7.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8722666&FileExtension=pdf&FileName=DCA19MA086%20Attachment%2015%20%20-%20First%20Officer%20PRIA%20Documentation%20(FINAL)_Redacted-Rel.pdf
- Operations attachment 16 - flight crewa��s resumes and atlas applications (item 17, PDF, 39 pages, 38.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8722785&FileExtension=pdf&FileName=DCA19MA086%20Attachment%2016%20-%20Flight%20Crew%E2%80%99s%20Resumes%20and%20Atlas%20Applications%20(FINAL)_Redacted-Rel.pdf
- Operations attachment 17 - FAA interview summaries (item 18, PDF, 9 pages, 280 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8722556&FileExtension=pdf&FileName=DCA19MA086%20Attachment%2017%20-%20FAA%20Interview%20Summaries%20(FINAL)_Redacted-Rel.pdf
- Operations attachment 18 - ac 120-68H pria (item 19, PDF, 71 pages, 890 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8722149&FileExtension=pdf&FileName=DCA19MA086%20Attachment%2018%20-%20AC%20120-68H%20PRIA%20(FINAL)-Rel.pdf
- Operations attachment 19 - atlas air pilot interview process (item 20, PDF, 17 pages, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8829481&FileExtension=pdf&FileName=DCA19MA086%20Attachment%2019%20-%20Atlas%20Air%20Pilot%20Interview%20Process%20(FINAL)-Rel.pdf
- Operations attachment 20 - atlas air pwp program (fotm revision) (item 21, PDF, 7 pages, 352 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8722015&FileExtension=pdf&FileName=DCA19MA086%20Attachment%2020%20-%20Atlas%20Air%20PWP%20Program%20(FOTM%20Revision)%20(FINAL)_Redacted-Rel.pdf
- Operations attachment 21- flight crew 72-hour history documents (item 22, PDF, 11 pages, 8.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8722345&FileExtension=pdf&FileName=DCA19MA086%20Attachment%2021-%20Flight%20Crew%2072-hour%20History%20Documents%20(FINAL)_Redacted-Rel.pdf
- Operations attachment 22 - atlas CRM training presentation (item 23, PDF, 56 pages, 3.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8722530&FileExtension=pdf&FileName=DCA19MA086%20Attachment%2022%20-%20Atlas%20CRM%20Training%20Presentation%20(FINAL)_Redacted-Rel.pdf
- Operations attachment 23 - atlas air operational safety and crew concepts (item 24, PDF, 10 pages, 787 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8722675&FileExtension=pdf&FileName=DCA19MA086%20Attachment%2023%20-%20Atlas%20Air%20Operational%20Safety%20and%20Crew%20Concepts%20(FINAL)-Rel.pdf
- Operations attachment 24 - ASRS request SR7290 (item 25, PDF, 36 pages, 375 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8722794&FileExtension=pdf&FileName=DCA19MA086%20Attachment%2024%20-%20ASRS%20Request%20SR7290%20(FINAL)_Redacted-Rel.pdf
- Operations attachment 25 - other pilot statements (item 26, PDF, 10 pages, 676 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8722565&FileExtension=pdf&FileName=DCA19MA086%20Attachment%2025%20-%20Other%20Pilot%20Statements%20(FINAL)_Redacted-Rel.pdf
- Operations attachment 26 - witness statements (item 27, PDF, 12 pages, 542 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8856908&FileExtension=pdf&FileName=DCA19MA086%20Attachment%2026%20-%20Witness%20Statements%20(FINAL)_Redacted-Rel.pdf
- Operations attachment 27 - atlas air stall recovery guidance (item 28, PDF, 9 pages, 527 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8722235&FileExtension=pdf&FileName=DCA19MA086%20Attachment%2027%20-%20Atlas%20Air%20Stall%20Recovery%20Guidance%20(FINAL)-Rel.pdf
- Operations attachment 28 - atlas air upset recovery guidance (item 29, PDF, 9 pages, 526 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8722354&FileExtension=pdf&FileName=DCA19MA086%20Attachment%2028%20-%20Atlas%20Air%20Upset%20Recovery%20Guidance%20(FINAL)-Rel.pdf
- Operations attachment 29 - atlas air turbulence guidance (item 30, PDF, 5 pages, 279 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8856500&FileExtension=pdf&FileName=DCA19MA086%20Attachment%2029%20-%20Atlas%20Air%20Turbulence%20Guidance%20(FINAL)-Rel.pdf
- Operations attachment 30 - atlas air GPWS guidance (item 31, PDF, 4 pages, 260 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8722581&FileExtension=pdf&FileName=DCA19MA086%20Attachment%2030%20-%20Atlas%20Air%20GPWS%20Guidance%20(FINAL)-Rel.pdf
- Operations attachment 31 - mia B767 simulator observation (item 32, PDF, 52 pages, 12.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8722691&FileExtension=pdf&FileName=DCA19MA086%20Attachment%2031%20-%20MIA%20B767%20Simulator%20Observation%20(FINAL)_Redacted-Rel.pdf
- Operations mia B767 simulator observation video (runs 1.1 through 1.3) (item 33, MP4, 115 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8873759&FileExtension=MP4&FileName=Runs%201.1%20through%201.3-Rel.MP4
- Operations - mia B767 simulator observation video (runs 1.4 through 1.5) (item 34, MP4, 67.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8832942&FileExtension=MP4&FileName=Runs%201.4%20through%201.5-Rel.MP4
- Operations attachment 32 - party forms (item 35, PDF, 5 pages, 10.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8722371&FileExtension=pdf&FileName=DCA19MA086%20Attachment%2032%20-%20Party%20Forms%20(FINAL)_Redacted-Rel.pdf
- Operations attachment 33 - subpoenas (item 36, PDF, 10 pages, 9.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8722167&FileExtension=pdf&FileName=DCA19MA086%20Attachment%2033%20-%20Subpoenas%20(FINAL)_Redacted-Rel.pdf
- Flight data recorder ancillary specialist's factual report (item 37, PDF, 3 pages, 29 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8417637&FileExtension=pdf&FileName=DCA19MA086_UAL_N47505_Factual_FINAL-Rel.pdf
- Flight data recorder ancillary specialist's factual report - attachment 1 (tabular data) (item 38, CSV, 11.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8417739&FileExtension=csv&FileName=Attachment1_FDRAncillaryReport-Rel.csv
- Meteorology factual report (item 39, PDF, 35 pages, 10.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8493986&FileExtension=pdf&FileName=WX_DCA19MA086_Factual-Rel.pdf
- Attachment 1 to the meteorology factual report (item 40, PDF, 23 pages, 4.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8494084&FileExtension=pdf&FileName=WX_DCA19MA086_Attachment_1-Rel.pdf
- Attachment 2 to the meteorology factual report (item 41, PDF, 13 pages, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8494093&FileExtension=pdf&FileName=WX_DCA19MA086_Attachment_2_redacted-Rel.pdf
- Attachment 3 to the meteorology factual report (item 42, PDF, 16 pages, 711 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8494352&FileExtension=pdf&FileName=WX_DCA19MA086_Attachment_3-Rel.pdf
- Attachment 4 to the meteorology factual report (item 43, PDF, 4 pages, 792 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8494582&FileExtension=pdf&FileName=WX_DCA19MA086_Attachment_4_redacted-Rel.pdf
- Attachment 5 to the meteorology factual report (item 44, PDF, 10 pages, 8.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8494954&FileExtension=pdf&FileName=WX_DCA19MA086_Attachment_5-Rel.pdf
- Attachment 6 to the meteorology factual report (item 45, PDF, 26 pages, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8494591&FileExtension=pdf&FileName=WX_DCA19MA086_Attachment_6-Rel.pdf
- Attachment 7 to the meteorology factual report (item 46, PDF, 2 pages, 477 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8495280&FileExtension=pdf&FileName=WX_DCA19MA086_Attachment_7_redacted-Rel.pdf
- Attachment 8 to the meteorology factual report (item 47, PDF, 10 pages, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8494963&FileExtension=pdf&FileName=WX_DCA19MA086_Attachment_8-Rel.pdf
- Adsb data (item 48, CSV, 4.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8494892&FileExtension=csv&FileName=ADSB_data-Rel.csv
- Local video (item 49, MP4, 13.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8494901&FileExtension=mp4&FileName=Local_video-Rel.mp4
- Zhu cwsu video briefing about 0530 CST (item 50, MP4, 28.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8494910&FileExtension=mp4&FileName=ZHU_CWSU_video_briefing_about_0530CST-Rel.mp4
- Zhu cwsu video briefing about 1200 CST (item 51, MP4, 27.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8494784&FileExtension=mp4&FileName=ZHU_CWSU_video_briefing_about_1200CST-Rel.mp4
- Maintenance records (item 52, PDF, 38 pages, 3.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8520345&FileExtension=pdf&FileName=Maintenance%20Records_Redacted-Rel.pdf
- Air traffic control group factual report (item 53, PDF, 12 pages, 609 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8714261&FileExtension=pdf&FileName=ATC%20Group%20Factual%20Report-Rel.pdf
- Air traffic control attachment 1 - interview summaries (item 54, PDF, 22 pages, 166 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8713670&FileExtension=pdf&FileName=Attachment%201%20%E2%80%93%20Interview%20Summaries-Rel.pdf
- Air traffic control attachment 2 a�� radar data (item 55, PPB, 790 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8714006&FileExtension=ppb&FileName=Attachment%202%20%E2%80%93%20Radar%20data.ppb-Rel.ppb
- Air traffic control attachment 3 a�� aircraft accident package (item 56, PDF, 88 pages, 5.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8714440&FileExtension=pdf&FileName=Attachment%203%20%E2%80%93%20Aircraft%20Accident%20Package_Redacted-Rel.pdf
- Air traffic control attachment 4 a�� ATC audio recording (item 57, WAV, 124 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8714882&FileExtension=wav&FileName=Attachment%204%20%E2%80%93%20ATC%20Audio%20Recording-Rel.wav
- Air traffic control attachment 5 a�� mandatory occurrence report (item 58, PDF, 3 pages, 673 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8714756&FileExtension=pdf&FileName=Attachment%205%20%E2%80%93%20Mandatory%20Occurrence%20Report-Rel.pdf
- Air traffic control attachment 6 a�� linkk one star (item 59, PDF, 3 pages, 907 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8714891&FileExtension=pdf&FileName=Attachment%206%20%E2%80%93%20LINKK%20ONE%20STAR-Rel.pdf
- Air traffic control attachment 7 a�� ATIS recording (item 60, MP3, 5.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8713808&FileExtension=mp3&FileName=Attachment%207%20%E2%80%93%20ATIS%20Recording-Rel.mp3
- Air traffic control attachment 8 a�� ATC transcript (item 61, PDF, 5 pages, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8714449&FileExtension=pdf&FileName=Attachment%208%20%E2%80%93%20ATC%20Transcript_Redacted-Rel.pdf
- Airplane performance study (item 62, PDF, 13 pages, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8717289&FileExtension=pdf&FileName=DCA190MA086_airplane_performance_study_v4-Rel.pdf
- Powerplants factual report (item 63, PDF, 41 pages, 49 photos, 3.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8736387&FileExtension=pdf&FileName=Atlas%20HOU%20PP%20factual%20final-Rel.pdf
- Structures group chairman's factual report (item 64, PDF, 7 pages, 67 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8753012&FileExtension=pdf&FileName=DCA19MA086%20Structures%20Factual-Rel.pdf
- Structures group chairman's factual report-appendix a-figures (item 65, PDF, 31 pages, 30 photos, 10.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8752603&FileExtension=pdf&FileName=DCA19MA086%20Structures%20Appendix%20A%20-%20Figures-Rel.pdf
- Flight data recorder specialist's factual report (item 66, PDF, 21 pages, 5.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8844869&FileExtension=pdf&FileName=Flight%20Data%20Recorder%20Specilaist%27s%20Factual%20Report-Rel.pdf
- Flight data recorder specialist's factual report - attachment 1 (item 67, CSV, 57.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8844422&FileExtension=csv&FileName=Flight%20Data%20Recorder%20Specialist%27s%20Factual%20Report%20-%20Attachment%201-Rel.csv
- Cockpit voice recorder - group chairman's factual report (item 68, PDF, 54 pages, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8874373&FileExtension=pdf&FileName=DCA19MA086_CVR_Transcript6forIRELEASE-Rel.pdf
- CVR sound spectrum study (item 69, PDF, 13 pages, 312 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=20472192&FileExtension=pdf&FileName=DCA18MA086%20Sound%20Spectrum%20Study%20004-Rel.pdf
- Systems group chairman's factual report (item 70, PDF, 51 pages, 20 photos, 3.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8855473&FileExtension=pdf&FileName=DCA19MA086%20-%20Systems%20Factual%20-%20FINAL%20-%20DECEMBER%2016%202019-Rel.pdf
- Systems group chairman's factual report - attachment 1 - systems database of recovered and identified components (item 71, PDF, 7 pages, 766 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8855833&FileExtension=pdf&FileName=DCA19MA086%20-%20Systems%20Factual%20-%20ATTACHMENT%201%20-%20Systems%20Database%20of%20Parts-Rel.pdf
- Systems group chairman's factual report - attachment 2 - Boeing commercial airplanes equipment quality analysis report - examination of control stand thrust lever assembly (item 72, PDF, 25 pages, 32 photos, 6.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8855842&FileExtension=pdf&FileName=DCA19MA086%20-%20Systems%20Factual%20-%20ATTACHMENT%202%20-%20Boeing%20EQA%20Lab%20Report-Rel.pdf
- Systems group chairman's factual report - addendum 1 (item 73, PDF, 2 pages, 17 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9227367&FileExtension=pdf&FileName=DCA19MA086%20-%20%20Systems%20Factual%20-%20Addendum%201%20-%20FINAL%20-%203%20MARCH%202020-Rel.pdf
- Tech review errata sheet (item 74, PDF, 1 page, 102 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9162049&FileExtension=pdf&FileName=DCA19MA086%20-%20Atlas%20Technical%20Review%20Errata-Rel.pdf
- Party submission - Boeing (item 75, PDF, 11 pages, 443 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9162794&FileExtension=pdf&FileName=Boeing%20Submission%20Atlas%20N1217A_Redacted-Rel.pdf
- Party submission - ge (item 76, PDF, 1 page, 73 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9162694&FileExtension=pdf&FileName=GE%20Aviation%20Submission%20for%20DCA19MA086_Redacted-Rel.pdf
- Party submission - atlas (item 77, PDF, 11 pages, 6.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9161832&FileExtension=pdf&FileName=Atlas%20Party%20Submission%20and%20Exhibits_Redacted-Rel.pdf
- Party submission - ibt (item 78, PDF, 11 pages, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9163122&FileExtension=pdf&FileName=DCA19MA086%20IBT2750%20Submission%20to%20NTSB-Rel.pdf

From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model.

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