Fatal Error! How UPS Flight 1354 Ended in Disaster

- [Petter] You know how sometimes you need to make

a split second decision to change your plan,

only to find out that your new decision

just made things much, much worse?

Well, now imagine that this is happening to you

as you're about to land an aircraft in the middle of the night.

- [GPWS] Too low. Terrain. Pull up.

- Stay tuned.

Being a cargo pilot is a challenging

and often wonderful job.

Now I haven't had the luck of trying it out myself

but I have plenty of friends who have

and whilst most of them absolutely love it,

there is no getting away from the fact

that most cargo operations happens at night

and that comes with some real challenges.

During the early 2010s, there had been a fierce debate

in the United States about improvements

of pilot flight time limitations

and in January 2012, new rules were actually published.

Those provided more stringent limitations,

specifically for pilots conducting passenger transport,

but curiously, not for cargo pilots.

The cargo airlines had successfully lobbied

that these new rules would not be realistic

for their type of mostly nocturnal operation

and Instead pointed to their own fatigue management systems,

which they had negotiated with their own unions.

Now even though the cargo airlines

might have had a point there,

this was obviously a source of great frustration

among their pilots, which we will soon see here.

But no matter how you turn it,

the responsibility for turning up rested for a flight is

and has always been shared

between both the pilots, the airline and the regulator

and if any one of those doesn't do their part,

well, then pilot fatigue can be the result,

which is worth remembering for this story.

I will get to the accident flight very soon

but before that, I want to have a look

at the two pilots involved in this story

and how they spent their days

before this fateful flight.

The captain was 58 years old and had been working for UPS

for almost 23 years.

He had started his career in the military

and moved on to the regionals

and then finally to a flight engineer position

on the Boeing 727 for Transworld.

Now he worked in that position for a while

before he upgraded to first officer and interestingly,

we don't know exactly how much total time

he had before joining UPS.

But once he joined, he went back to being a flight engineer

before again upgrading to first officer on the Boeing 727.

Now according to internal UPS records,

he then tried to upgrade to captain on the Boeing 757 twice

in the year 2000 but ended up

withdrawing voluntarily from both of those courses

since he found them too overwhelming.

Instead, in 2004, he changed over

to the Airbus A300 fleet where he continued flying

in the right seat for several years

before finally upgrading to captain in 2009.

His total flying experience in UPS was around 6,400 hours

of which 3,265 had been flown on the Airbus A300.

Now another thing that's worth pointing out about the captain

was that he had received poor grades

on a few occasions on his recurrent training sessions,

specifically around his knowledge

and execution of non-precision approaches.

He had, for example on a few occasions,

flown below the minimum descent altitude among other things.

But that had happened during training sessions

where the objective was to train to proficiency

so it had never caused any actual failed checkrides.

He was well liked by his colleagues

who described him as a diligent,

nice and competent pilot,

open to taking inputs from his colleagues.

But during the month before this flight,

he had begun to complain about the roster,

saying that it was getting harder and harder

with more and more legs having to be flown

and that he doubted that he would have

the energy to continue flying like that until he retired.

During the days before the accident flight,

the captain had, according to his wife,

been sleeping normally and had, before he started his duty,

tried to take regular naps in order to change

his body rhythm over from day to night shift.

During the evening before the accident flight,

his wife had dropped him off

at the UPS facility in Charlotte, North Carolina

where he had then flown as a passive crew member

over to Louisville.

Once he arrived there, he booked a sleep room

at the UPS crew facilities and napped for a few hours

before his shift started,

which means that he was likely reasonably well rested

and without any huge sleep debt at that point.

The first officer was 37 years old

and had been flying for both corporate

and regional operators before she was hired by UPS

as a 727 flight engineer back in 2006.

She quickly moved over to the 757 fleet

where she upgraded to first officer

and she then transitioned over to the 747

on which she stayed for a few years.

Then in 2012, she was again moved over

to the Airbus A300 where she had been operating ever since.

Her total time was just over 4,700 hours and out of those,

she had only flown around 400 hours on the Airbus

at the time of this flight.

Her training records were clean

and she was described as a top-notch person

with good flying skills and her captains liked flying with her.

But she had recently also started complaining

about the roster and how she barely

could keep her eyes open in flight sometimes.

On one occasion in March 2013,

a colleague had actually found her sitting

with her face down on a table in the crew room

complaining about being totally and completely exhausted.

Before the accident flight she had

started her shift flying one night flight

before having a further long break.

She then used that break by going visiting a friend

in Houston before on the following day going back

on a jump seat flight to San Antonio

and resuming her duty.

That duty included flying over from San Antonio

to Louisville in the late evening

of the 12th of August, where she would be crewed together

with the captain of this story.

Now even though she had mentioned

to her husband that she had been sleeping a lot

when she was visiting her friend,

her use of personal electronic equipment showed

that she'd really hadn't gotten

that much coherent sleep there

and that pattern continued throughout

the following day and night as well.

So this meant that it is likely that the first officer

had a substantial sleep debt

when her shift with the accident captain started

on the 13th of August, the day before the accident.

The two pilots met up in the UPS crew room in Louisville

around 02.30 in the morning

and started preparing their flights together.

Everything looked fine,

so they eventually just walked out the aircraft,

prepared it for departure and then took off

for their first flight over to General Downing in Peoria

and then their second to Chicago Rockford

where they had their scheduled night stop.

These flights were completely uneventful

and they ended up signing into their hotel rooms

at around 06.30 in the morning.

But already at around 10:45, only four hours later,

the first officer was seen having breakfast

in the hotel restaurant.

And she then was active on and off during the day

until it was time to sign in for their next duty.

It is likely that she had a few naps during the day

but not enough to cancel out that sleep debt

that she was now undoubtedly carrying with her.

The captain, on the other hand,

seemed to have rested properly during the night stop.

So he was in a quite good mood

as the hotel shuttle brought them out to the airport

at around 10 minutes past eight in the evening.

The duty that they had ahead of them

was what's known as a split duty

where they would be operating two flights

in the late evening followed by a few hours of rest

and then another flight in the very early morning.

They again started by going through the planning documents

which their dispatcher had prepared for them

and saw that there would be no major issues

during at least their first two flights.

They decided on fuel to take and then they walked

out of the aircraft and started it up as normal,

having no idea what was soon about to happen

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Before they started, they had decided

that the captain would be pilot flying for the first flight

from Rockford over to Peoria

and then the first officer was going

to fly the second from Peoria over to Louisville.

Both flights went off without any problems

and when they finally landed in Louisville around midnight,

they saw that they would have an almost three-hour long break

until it was time for their last flight

over to Birmingham-Shuttlesworth Airport.

This was plenty of time to get some shut-eye

so both pilots booked a sleep room

at the UPS facilities to try

to get the most out of the break.

Now at this point, you might be wondering

what the routines actually were at UPS for avoiding fatigue.

I've already mentioned that cargo airlines

had been exempted from the coming rule changes

regarding crew flight time limitations

but that didn't mean that they weren't any rules in place.

In fact, UPS had negotiated with the unions rules

that were supposed to mitigate the threat of fatigue

and those rules were significantly stricter

than the minimum required at the time.

One super important part

of those rules was the pilot's ability to call in fatigue

whenever they felt that it was needed

and in that case, being taken off the roster immediately

with no questions asked.

This facility was available for all pilots,

but there were some strings attached to it.

You see UPS had put in force something known

as a sick bank where a certain amount of days

were available for each pilot every year.

A bonus on top of their regular pay

would then be paid out at the end of the year

based on the amount of days that were still left in that bank.

If a pilot called in fatigued, this would then be investigated

by a dedicated manager and if it was found

that the call was made unfairly

as in if the pilot had actually had enough rest

to avoid fatigue but hadn't used it properly

well, then a day would be removed

from that pilot's sick bank.

This was supposed to work as a positive incentive

for the pilots but anyone who knows humans

knows how quickly something like that

will start to be seen as a punishment instead

and how people will try to avoid losing out on that bonus

in whatever way they could.

At around 02:45 on the 14th of August,

the two pilots came out of their sleep rooms

and started preparing for their final flight.

Both of them had managed to get a bit of sleep

and they now started looking through the briefing material

that their flight dispatcher had once again prepared for them.

On the weather side, they showed a weak front

that was present just north of the Birmingham area

with a low pressure gradient,

meaning that they could expect very light winds,

but also some quite low clouds at around 400 feet.

The low clouds were clearing slowly

from the south so at the time the pilots

were looking at the observations,

the cloud ceiling was variable

between 600 and 1,100 feet.

On top of this there was also

a active notice to airmen, NOTAM,

which indicated that the main runway

at the destination airport, Runway 06/24

would be closed for some work

on the runway lights between 0400 and 0500.

Now their flight was scheduled

to arrive about 10 minutes before the runway

would be reopened again so this left

only Runway 18 available for landing.

This runway was significantly shorter than the main one,

7,099 feet instead of 11,998 and it also didn't have

an ILS precision approach available to it.

Instead there was a localizer

and an RNAV GPS non-precision approach available

and with the clouds as low as they were now indicating,

this would require an extra alternate to be filed

since it was a high likelihood

that the pilots wouldn't be able to see

the runway from the higher minimas of those approaches

The dispatcher who had been planning this flight

was well aware of this and had, therefore,

planned for Runway 18 to be used

but he didn't reach out to the crew directly

to communicate this slightly unusual circumstance.

He felt that it was up to the pilots to reach out to him

if they had any questions and he didn't want

to reach out and possibly insult the captain

with the information that he thought would be obvious.

At the time the dispatchers in the US

went through annual recurrent training

to keep their planning skills high

and also something known as DRM,

Dispatchers Resource Management,

but that training never included any pilots.

If that would have been the case,

the dispatcher would have probably known

that we pilots always appreciate any help that we can get

and no operational information

would be seen as improper or insulting.

And, in fact, on this occasion it looks

like the pilots indeed missed that NOTAM

about the closed runway as some later discussions

in the cockpit will soon show.

And the fact that this whole thing

could have likely been avoided

if the flight was just operationally delayed

by about 15 minutes or so

to allow the main runway to open

is just truly, truly tragic.

In any case, the pilots now finished up

their preparation and then ordered fuel

for the short 45 minutes hop down towards Birmingham.

Since the first officer had flown the previous flight,

the captain would now be flying.

So as soon as they got out of the aircraft,

he started setting it up for departure

as the first officer did the walk-around

and checked on the cargo loading.

The aircraft they were operating

was a 10-year-old Airbus A300

powered by two enormous Pratt & Whitney 4158 turbofan engines

and it was in great condition.

The pilots had asked for 34,650 pounds of fuel

and with a cargo of 89,227 pounds.

It would mean that they would be landing only 17,000 pounds

below the max landing weight,

meaning that they were quite heavy this morning.

When the first officer came back into the cockpit,

the captain gave her a departure briefing

and then finished up the last part

of the pre-flight preparation and checklist.

They then had to wait a little bit

for the final cargo loading to be completed.

And during that time they chatted

a bit about how they were feeling.

The first officer mentioned that she

had been feeling so tired when the alarm went off.

And they then continued discussing the unfairness

of the fact that they, cargo pilots,

would not be included in the new flight time limitations

that were being negotiated

like if there were second class pilots or something.

Now I want to clearly point out here

that these new rules for passenger-carrying pilots

was not yet in force at this point and even if they had been,

these pilots would have still been legal to fly

even if they had been subjected to those new rules.

The captain had only had a slightly shorter rest

than required under the new rules

a few months earlier and the first officer

was well within these new limits.

Anyway, they soon received the last pieces of paperwork

and at time 03:55, Flight 1354

requested pushback from the gate

and started moving towards their departure runway,

Runway 35 Right.

During the taxi-out the discussions in the cockpit

were professional and to the point

and at time 04:02, the captain advanced

the thrust levers in the cockpit

and the giant Airbus started accelerating down the runway.

The take-off was completely normal

and they initially climbed straight ahead

towards 5,000 feet according to their departure clearance.

They retracted the flaps and slats on schedule

and were soon handed over to the departure frequency

where the controller cleared them

to climb to 10,000 feet and to turn

onto an easterly radar heading

before finally clearing them south

down towards a VOR called BOWLING GREEN.

The first officer entered that VOR

into the flight management computer

and called out, "NAV available"

and the captain engaged the NAV mode.

Now this mode, the NAV mode,

will play an important role in what's soon about to happen.

You see modern aircraft generally follow

a predetermined flight plan

that have been approved by air traffic control,

long before the flight actually starts.

A part of pilot flying's preflight preparation

is to enter this flight plan

into the flight management computer

and after that, verify it carefully and then execute it

so it can be used in flights

When air traffic control then, after departure,

clears the aircraft to a specific point,

in this case the BOWLING GREEN VOR,

the pilot will just select that waypoint

at the top of the active flight plan,

verify that it looks correct

on the navigation display and then execute that routing.

Providing that the aircraft's autopilot

is then active in the NAV mode,

it will turn and follow this new routing

and after that, to whatever waypoint

that lies behind it, according to the flight plan.

Air traffic control will assume

that the aircraft is following the pre-approved flight plan

so there is no need to give any further clearances

unless they want to give them a shortcut, for example.

And this is how air traffic control

can actually handle thousands of flights per day

because the aircrafts are basically navigating autonomously.

Now using that flight plan,

the flight management computer

will also be able to calculate when they should start

to descend, for example, based on its calculated track miles

and as long as nothing changes,

we pilots will basically just need to ask for descent

then manage the aircraft's speed and configuration.

The navigation, both laterally and vertically

will be done perfectly by the computer.

But the FMC is not an intelligent computer

and will only do exactly what it's told.

Because of that, it is susceptible

to something we pilots refer to as sh-- in sh-- out,

meaning that if we don't program it properly,

it can start showing all sorts of wrong information

and that's worth keeping in mind.

The aircraft was eventually cleared

to climb to their cruise level of flight level 280.

And around that same time, the controller also told them

to continue straight towards Birmingham Airport.

Now this clearance would wipe out

all of the other points that the pilots had entered

into their flight plan and just replace them

with a straight line towards their destination airport.

In order to make that happen,

the first officer would have entered

the airport's ICAO identification code, KBHM,

into the FMC and then put that on top

of the legs page as the new active waypoint,

basically telling the aircraft to just fly there.

But, of course, in reality,

the aircraft wouldn't actually fly

all the way to the airport.

At some point, they would have

to break away from this direct routing

and intercept an instrument approach

into whatever runway they would use at Birmingham

and the pilots obviously knew that.

If a direct like this is entered

and nothing else is done

to crop the route into something more realistic,

the aircraft's FMC will assume that the pilots will fly

all the way until they're overhead the airport

and then turn back out and fly

whatever approach they had planned for,

adding a lot more track miles to the route

than they would actually fly.

Like I said, it is a little bit stupid.

So the way this is normally dealt with

at least in my airline, is that the pilot monitoring

will then create a new waypoint

which is maybe 20 nautical miles short of the airport

on the direct two leg and then connect

that new waypoint with whatever approach they're expecting.

This will then obviously have to be very closely monitored

that it's not actually the clearance

they've been given, just an estimation

but it will give a far more accurate picture

of what is likely going to happen

and therefore help the FMC

to calculate a more accurate descent path.

But in this case, this was not done and neither

of the pilots noticed this discrepancy.

On the legs page in the FMC/CDU,

this issue was shown as a route discontinuity message

after the KBHM point, letting the pilots know

that the FMC didn't know what they wanted to do after that.

Anyway, soon after this direct routing was received,

the first officer went off-frequency

to listen to the Birmingham

Automatic Terminal Information Service, ATIS

and to write down the weather and approach information.

ATIS information Papa was active

and it said that the winds were calm,

visibility 10 miles with a broken cloud layer at 1,000 feet

and another one at 7,000 feet.

On top of that, it also informed the pilots

that the localizer for Runway 18 was in use

since Runway 06/24 was closed.

The information of the runway closure

apparently came as news to the pilots

with the captain just commenting,

"(sighs) Localizer one eight, it figures."

This just showed that he probably felt

a little bit frustrated with having to fly

a much more complicated maneuver

at five o'clock in the morning.

The first officer also chimed in and pointed out

that this was typical because they were a little bit heavy

and now they had to land on a much shorter Runway 18.

Again, this information had been available to them

on the planning stage and if they would have read it,

they would have also known

that the main runway was scheduled

to open less than 15 minutes

after their scheduled arrival time.

Another thing that I want to point out here

is that even though the ATIS and also some EICAS messages

that the crew had received

showed a nice and high cloud base

of around 1,000 feet over the ground,

the reality was actually a bit different.

There were scores of lower clouds still present in the area,

bringing the cloud base down to as low as 300 feet in places

but at the time of this observation,

none of those were present exactly over the runway

where the cloud base was being measured

The meteorologist who had sent out this weather

had included this information in a special note

but because of some issues with the EICAS weather formatting,

UPS had actually stopped including those type of notes

in the weather report sent out to the aircrafts.

And the same actually went for the tower controller

who had updated the ATIS.

He could also have included

those type of side notes in the ATIS if he wanted

but there were no clear instructions on exactly what type

of weather that needed to be included in those type of notes

so he had just skipped it.

What that all meant was that as the captain

was now starting to prepare

for the localizer non-precision approach,

he and his colleague had likely a mental model

of the weather which was dramatically better

than what it actually was.

And that brings us to the type of approach

that they were now preparing to fly.

Like I already mentioned, it was a localizer approach

and as its name suggests,

it's flown using a localizer signal as the horizontal guidance.

The localizer is obviously one half of an ILS approach

but without the glideslope vertical guidance,

meaning that it's much more complicated to fly

and gives less guidance hence it's regarded

as a non-precision approach

In a few of my previous videos,

I've explained that non-precision instrument approaches

who are flown without vertical guidance

can be flown either as a constant descend approach, CDA,

or a step-down approach where the safest option is the CDA.

A constant descent will ensure a more stabilized approach

without any large changes in trim and thrust needed

to level off between the different minimum altitudes

so this was what the crew were now preparing for.

A CDA could be flown either with the use of vertical speed

and carefully verifying distances versus calculated altitudes

or with the use of the vertical nav path option

where the aircraft would be flying a pre-programmed path

down to a specific altitude over the threshold.

And that's what the captain was now planning for.

He started his briefing by going

through a special non-precision approach checklist

which highlighted all the important steps

including which minimum descent altitude, MDA, to use,

in this case 1,200 feet and they then continued

with how the approach was going to be flown,

including all of the relevant points

on the instrument approach charts.

As the captain was briefing the first officer was dealing

with the radios and was soon handed over

to the Atlanta Center Controller.

This new controller told them to descend to flight level 240

at their own discretion and the first officer read that back.

And at the same time, a FedEx aircraft

with the same call sign number, FedEx 1354,

also appeared on the frequency

and when they heard this, both pilots mentioned

this potential threat of ATC mixing up their call signs.

This, at least to me, showed

that they were both pretty switched on at this point

and well into the game.

The captain initiated their descent at time 04:32

and when they formed the controller about this,

he did indeed mix them up with the FedEx aircraft,

which the two pilots had a little chuckle about.

All in all, the atmosphere in the cockpit

was pretty good at this point.

Next, they were handed over

to the Memphis control center where they were soon cleared

to descent further, down to 11,000 feet.

This was also read back by the first officer

and after the captain had selected this new altitude

in the mode control panel, he said, "They're generous today.

Usually they kind of take you to 15

and then they hold you up high."

And this, the captain's anticipation of being held high

by ATC will soon become important.

Next, they were handed over

to the Atlanta Controller who gave them

the latest altimeter setting for Birmingham,

29.96 inches of mercury and once the crew had set this,

the captain asked for the approach checklist.

So far, this flight was flown perfectly according

to UPS standard procedures but that would soon change.

At around 04:40, the background sound

on the cockpit voice recorder could be heard decreasing,

which is a sign of the aircraft slowing down.

As this was happening, the captain said, "One to go,"

which was likely said as a reminder for the first officer

since it was actually her who should have called that.

She repeated it and then told the captain

that she would ask for lower.

What was likely going on here was

that the aircraft had been descending

down towards 11,000 feet according to its pre-programmed path,

but as they were now getting closer,

the captain started to reduce the speed

to slow the descent down

but also to reduce their kinetic energy, speed,

instead of their potential energy, altitude.