Fatal Error! How UPS Flight 1354 Ended in Disaster

Mentour Pilot
11 May 202440:59

Summary

TLDRThe video script recounts a tragic incident involving a UPS cargo plane that crashed while attempting to land at Birmingham-Shuttlesworth Airport. The pilots, despite being experienced, continued an unstabilized approach and failed to monitor their altitude, leading to a descent below the minimum descent altitude and a subsequent crash. The investigation into the accident revealed probable causes, including fatigue, inadequate rest, and a lack of proper communication regarding runway conditions. The video emphasizes the shared responsibility for addressing pilot fatigue and the need for better training and communication to prevent such incidents. It also discusses the importance of following standard procedures and the potential impact of human factors on flight safety.

Takeaways

  • ✈️ The accident involved a UPS Airbus A300 cargo plane approaching an airport at night with a crew that had not been adequately rested, highlighting the risks of pilot fatigue.
  • 📉 The crew failed to follow proper procedures regarding the flight management computer (FMC), leading to a misinterpretation of their approach path.
  • ⚠️ The pilots did not adhere to the planned constant descent approach (CDA) and instead flew an unstabilized approach, which contributed to the accident.
  • 🛰️ There was a lack of communication between the flight dispatcher and the pilots about the closed runway, which would have required a different approach.
  • 🕒 The crew did not utilize the available rest time efficiently, which likely impacted their performance and decision-making during the flight.
  • 📋 The investigation revealed that the crew did not follow the standard operating procedures, including not setting the correct missed approach altitude.
  • 🔍 The crew's situational awareness was compromised, as they failed to notice the flight plan discontinuity and did not correct their approach path.
  • 😴 The first officer was suffering from a significant sleep debt, which likely affected her performance and contributed to the accident.
  • 🚨 The Ground Proximity Warning System (GPWS) provided a late warning due to the aircraft's proximity to the airport, which was insufficient to prevent the crash.
  • ⛔ The crew did not initiate a go-around when they reached the minimum descent altitude without visual contact with the runway, which is a critical safety protocol.
  • 🔑 Key lessons from the accident included the importance of proper rest, adherence to standard procedures, and the need for better communication and training to manage fatigue and operational risks.

Q & A

  • What were the challenges faced by cargo pilots that were discussed in the script?

    -The challenges faced by cargo pilots include flying mostly at night, which comes with difficulties such as fatigue and the need for proper rest and sleep management.

  • Why were new flight time limitations for pilots published in January 2012 in the United States?

    -The new flight time limitations were published to provide more stringent limitations for pilots, specifically for those conducting passenger transport, in response to safety concerns and debates during the early 2010s.

  • Why were cargo pilots exempt from the new flight time limitations?

    -Cargo airlines successfully lobbied for an exemption from the new rules, arguing that these rules would not be realistic for their mostly nocturnal operations, and instead relied on their own fatigue management systems.

  • What was the role of the captain and first officer in the accident flight?

    -The captain and first officer were responsible for operating the aircraft. Their actions, decisions, and the way they managed their fatigue played a significant role in the events leading up to the accident.

  • What was the captain's background and experience with UPS?

    -The captain was 58 years old and had been working for UPS for almost 23 years. He started his career in the military, moved to regional airlines, and then became a flight engineer on the Boeing 727 for Transworld before joining UPS.

  • What were the fatigue-related issues that the first officer faced?

    -The first officer had a substantial sleep debt due to inefficient use of her scheduled rest time, and she had been complaining about the roster and difficulty staying awake during flights.

  • What was the significance of the NOTAM regarding the runway closure at the destination airport?

    -The NOTAM indicated that the main runway at the destination airport would be closed for work on the runway lights, which meant that only a shorter runway with no ILS precision approach was available for landing.

  • Why was the Airbus A300's FMC not properly set up for the approach?

    -The FMC was not properly set up because the waypoints for the approach were never updated or sequenced after the aircraft was cleared for a direct route to the airport. This led to a flight plan discontinuity and incorrect navigation information.

  • What was the probable cause of the accident according to the investigation?

    -The probable cause of the accident was the pilot's continuation of an unstabilized approach and their failure to monitor the aircraft's altitude, leading them to descend below the minimum descent altitude and into terrain.

  • What were the recommendations made after the investigation to prevent similar accidents?

    -Recommendations included more collaborative training on fatigue management, making constant descent approaches mandatory for commercial aircraft, providing more information to pilots about lower GPWS warning margins, and improving cockpit warnings when the FMC is not properly set up.

  • Why was the GPWS warning late in this scenario?

    -The GPWS warning was late because the aircraft was so close to the airport that the warning envelope had been reduced to avoid nuisance warnings, and the controller did not receive any advance warnings about the aircraft's situation.

Outlines

00:00

😀 Introduction to Cargo Pilot Challenges and Fatigue Management

The video begins by highlighting the split-second decisions that cargo pilots must make, especially during challenging night landings. It discusses the demanding nature of cargo piloting, the prevalence of night operations, and the unique fatigue challenges faced. The segment also touches on the debate over pilot flight time limitations in the US during the early 2010s, the publication of new rules in 2012 that did not apply to cargo pilots, and the frustration this caused among pilots. The responsibility of managing fatigue is emphasized to be shared among pilots, airlines, and regulators.

05:00

👨‍✈️ Background of the Pilots and Their Preceding Schedules

The video provides a detailed background of the two pilots involved in the incident. The captain, a 58-year-old with nearly 23 years of experience at UPS, had a history of suboptimal performance in recurrent training sessions but was well-liked and respected. Before the flight, he had expressed concerns about his roster and fatigue. The first officer, 37 years old, had a clean training record and was considered a top-notch pilot. However, she had also been experiencing fatigue and had not managed to get adequate rest before the flight. The video outlines their activities and rest periods leading up to the accident flight.

10:03

🛫 The Flight Itinerary and the Pilots' Preparations

The pilots' flight itinerary is described, detailing their first two uneventful flights and their scheduled night stop. The first officer's struggle with fatigue continues as she tries to catch up on sleep without success. The captain, on the other hand, seems well-rested. They prepare for their final flight, a split duty with two flights and a break in between. The video also discusses the use of NordVPN by the video team for security and access to better prices, and a sponsorship message is included.

15:04

🚨 The Approach to Birmingham and the NOTAM Oversight

As the pilots prepare for their final flight to Birmingham, they review the briefing material which indicates low clouds and a weak front near the airport. A NOTAM warns of the closure of the main runway, leaving only a shorter runway available for landing. This information is not communicated directly to the pilots by the dispatcher, leading to a critical oversight. The pilots, unaware of the closed runway, do not file an alternate approach and continue with their preparations. The aircraft is described as being in great condition, and the pilots proceed with their flight.

20:06

🛬 Descent and Approach to Birmingham Airport

The pilots are cleared for their descent and approach to Birmingham Airport. The first officer listens to the ATIS, which provides crucial weather information and the fact that Runway 18 is in use. This information surprises the pilots, who were not aware of the runway closure. The video explains the process of navigating using the flight management computer (FMC) and the importance of updating the waypoints. However, the pilots fail to update the FMC correctly, leading to a discrepancy in the expected flight path.

25:07

📉 Descent Below Minimums and the Approach to Runway 18

The pilots continue their descent, but the captain's concern about being 'kept high' by ATC leads to a series of decisions that result in an unstabilized approach. The captain selects a higher descent rate than is standard, and the first officer fails to call out the approach minimums as required. The crew misses the opportunity to initiate a missed approach when they pass below the minimum descent altitude without visual contact with the runway. The aircraft's descent continues, and the pilots do not realize their altitude and position relative to the runway.

30:09

⚠️ GPWS Activation and The Tragic Impact

As the aircraft continues to descend well below the minimum descent altitude, the Ground Proximity Warning System (GPWS) issues a 'Sink Rate' warning, indicating a potentially dangerous descent rate. The captain spots the runway at a dangerously low altitude, but it is too late to avoid a collision. The aircraft strikes trees and power lines before crashing into an earth mound, resulting in a catastrophic impact that claims the lives of both pilots. The video describes the confusion among the rescue teams and the delayed response to the crash.

35:09

🔍 Investigation Findings and Recommendations

The investigation into the accident identifies the probable cause as the pilots' continuation of an unstabilized approach and their failure to monitor the aircraft's altitude. The report highlights the role of fatigue, especially the first officer's significant sleep debt, and the lack of effective communication regarding the runway closure. Recommendations include improved collaborative training on fatigue management, making constant descent approaches mandatory for commercial aircraft, and enhancing cockpit warnings for improper FMC setup. Airbus is also advised to make automatic call-outs standard. The video concludes with an invitation for viewers to join the creator's Patreon for further discussion.

Mindmap

Keywords

💡Split second decision

A split second decision refers to a choice that must be made very quickly, often in emergency situations or under high-pressure circumstances. In the video, it is mentioned in the context of making a rapid decision while landing an aircraft at night, which can lead to disastrous outcomes if made incorrectly.

💡Cargo pilot

A cargo pilot is a professional who operates aircraft to transport goods and cargo rather than passengers. The video discusses the challenges of being a cargo pilot, particularly the fact that most cargo operations occur at night, which presents unique difficulties and risks.

💡Pilot fatigue

Pilot fatigue refers to the physical and mental exhaustion that can affect a pilot's performance and decision-making abilities. The video emphasizes the importance of managing fatigue among pilots, as it can lead to serious accidents if not properly addressed.

💡Flight time limitations

Flight time limitations are regulations that restrict the number of hours a pilot can work or fly within a certain period to prevent fatigue. The video discusses changes to these rules in the United States and how they affected cargo pilots differently than passenger transport pilots.

💡Non-precision approach

A non-precision approach is an aircraft landing maneuver that uses only the horizontal guidance from a localizer signal without vertical guidance from a glideslope. The video describes how this type of approach is more complex and requires additional planning and execution, which can be challenging in low visibility conditions.

💡Minimum Descent Altitude (MDA)

The Minimum Descent Altitude (MDA) is the lowest altitude at which a pilot can safely continue a descent during an instrument approach without visual reference to the ground. The video highlights the importance of adhering to the MDA to avoid descending too low and potentially hitting obstacles.

💡Ground Proximity Warning System (GPWS)

The Ground Proximity Warning System (GPWS) is an aircraft system designed to alert pilots when there is a risk of collision with the ground or an obstacle. In the video, the GPWS issues a 'Too low, terrain' warning, indicating the aircraft was dangerously close to the ground.

💡Circadian low

Circadian low refers to the natural dip in a person's alertness and performance that occurs due to the body's internal clock, typically experienced in the early morning or late at night. The video suggests that the effects of flying during a circadian low, combined with fatigue, may have contributed to the pilots' impaired judgment.

💡Flight Management Computer (FMC)

The Flight Management Computer (FMC) is an advanced system used on modern aircraft to manage the flight plan, navigation, and fuel consumption. The video details how the FMC was not properly set up for the approach, leading to incorrect flight path information and contributing to the accident.

💡Stabilized approach

A stabilized approach is a term used to describe an aircraft's descent and approach to landing that is within predefined parameters for speed, rate of descent, and configuration, ensuring a safe and controlled landing. The video discusses how the pilots failed to maintain a stabilized approach, which was a critical factor in the accident.

💡NOTAM (Notice to Airmen)

A Notice to Airmen (NOTAM) is a notification filed in an official publication that contains information essential to personnel concerned with flight operations but not known far enough in advance to be included in the Airway Manual. The video mentions a NOTAM about a closed runway that the pilots overlooked, which affected their approach and contributed to the accident.

Highlights

The transcript describes a challenging scenario where a cargo plane is landing at night, highlighting the unique difficulties faced by cargo pilots.

A debate in the US during the early 2010s led to new flight time limitations for passenger transport pilots, but not for cargo pilots due to the nocturnal nature of cargo operations.

Cargo airlines lobbied for exemptions from new rules, citing their own fatigue management systems, which led to frustration among pilots.

The responsibility for addressing pilot fatigue lies with pilots, airlines, and regulators, with a failure by any party potentially leading to fatigue-related incidents.

The captain's background and experience with UPS, including his transition from military to regional flights and his eventual upgrade to captain, is detailed.

The captain had received poor grades in recurrent training sessions, particularly in non-precision approaches.

The captain's concerns about the roster's impact on fatigue and his struggle to maintain energy levels are discussed.

The first officer's career progression with UPS, her clean training records, and the recognition by her peers are highlighted.

The first officer's recent complaints about rosters and exhaustion, including an incident where she was found extremely tired, are mentioned.

The pilots' schedules and rest periods before the accident flight are outlined, indicating potential sleep debt issues.

The lack of communication regarding the closed runway and the reliance on pilots to seek clarification are criticized.

The potential for avoiding the accident by delaying the flight to use the main runway is discussed, highlighting a missed opportunity for prevention.

The aircraft's heavy landing weight due to its cargo is noted, which could have influenced the approach and landing strategy.

The pilots' failure to update the flight management computer (FMC) properly, leading to a faulty approach path, is a key oversight.

The captain's incorrect assumption about being 'kept high' by ATC and the resulting unstabilized approach is identified as a critical error.

The crew's missed opportunities to recognize and correct their descent profile, including the lack of callouts for minimums, are discussed.

The final moments of the flight, including the GPWS warnings and the ultimate crash, are detailed, emphasizing the tragic outcome.

Investigation findings point to the probable cause of the accident being the pilot's continuation of an unstabilized approach and failure to monitor altitude.

Recommendations from the investigation include improved training on fatigue, mandatory constant descent approaches, and enhanced cockpit warnings.

Transcripts

00:00

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

00:02

a split second decision to change your plan,

00:04

only to find out that your new decision

00:06

just made things much, much worse?

00:09

Well, now imagine that this is happening to you

00:11

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

00:14

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

00:16

- Stay tuned.

00:23

Being a cargo pilot is a challenging

00:25

and often wonderful job.

00:28

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

00:30

but I have plenty of friends who have

00:32

and whilst most of them absolutely love it,

00:35

there is no getting away from the fact

00:37

that most cargo operations happens at night

00:40

and that comes with some real challenges.

00:43

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

00:47

in the United States about improvements

00:48

of pilot flight time limitations

00:50

and in January 2012, new rules were actually published.

00:55

Those provided more stringent limitations,

00:57

specifically for pilots conducting passenger transport,

01:00

but curiously, not for cargo pilots.

01:03

The cargo airlines had successfully lobbied

01:05

that these new rules would not be realistic

01:08

for their type of mostly nocturnal operation

01:10

and Instead pointed to their own fatigue management systems,

01:13

which they had negotiated with their own unions.

01:16

Now even though the cargo airlines

01:18

might have had a point there,

01:19

this was obviously a source of great frustration

01:22

among their pilots, which we will soon see here.

01:25

But no matter how you turn it,

01:27

the responsibility for turning up rested for a flight is

01:30

and has always been shared

01:32

between both the pilots, the airline and the regulator

01:35

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

01:38

well, then pilot fatigue can be the result,

01:41

which is worth remembering for this story.

01:43

I will get to the accident flight very soon

01:45

but before that, I want to have a look

01:47

at the two pilots involved in this story

01:49

and how they spent their days

01:50

before this fateful flight.

01:53

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

01:56

for almost 23 years.

01:58

He had started his career in the military

02:00

and moved on to the regionals

02:02

and then finally to a flight engineer position

02:04

on the Boeing 727 for Transworld.

02:07

Now he worked in that position for a while

02:09

before he upgraded to first officer and interestingly,

02:11

we don't know exactly how much total time

02:14

he had before joining UPS.

02:16

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

02:19

before again upgrading to first officer on the Boeing 727.

02:23

Now according to internal UPS records,

02:25

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

02:29

in the year 2000 but ended up

02:31

withdrawing voluntarily from both of those courses

02:34

since he found them too overwhelming.

02:37

Instead, in 2004, he changed over

02:39

to the Airbus A300 fleet where he continued flying

02:41

in the right seat for several years

02:43

before finally upgrading to captain in 2009.

02:47

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

02:51

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

02:56

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

02:58

was that he had received poor grades

03:00

on a few occasions on his recurrent training sessions,

03:03

specifically around his knowledge

03:05

and execution of non-precision approaches.

03:08

He had, for example on a few occasions,

03:10

flown below the minimum descent altitude among other things.

03:15

But that had happened during training sessions

03:17

where the objective was to train to proficiency

03:20

so it had never caused any actual failed checkrides.

03:24

He was well liked by his colleagues

03:26

who described him as a diligent,

03:27

nice and competent pilot,

03:29

open to taking inputs from his colleagues.

03:32

But during the month before this flight,

03:34

he had begun to complain about the roster,

03:37

saying that it was getting harder and harder

03:39

with more and more legs having to be flown

03:41

and that he doubted that he would have

03:43

the energy to continue flying like that until he retired.

03:47

During the days before the accident flight,

03:49

the captain had, according to his wife,

03:51

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

03:54

tried to take regular naps in order to change

03:56

his body rhythm over from day to night shift.

03:59

During the evening before the accident flight,

04:01

his wife had dropped him off

04:02

at the UPS facility in Charlotte, North Carolina

04:05

where he had then flown as a passive crew member

04:07

over to Louisville.

04:09

Once he arrived there, he booked a sleep room

04:11

at the UPS crew facilities and napped for a few hours

04:14

before his shift started,

04:15

which means that he was likely reasonably well rested

04:18

and without any huge sleep debt at that point.

04:21

The first officer was 37 years old

04:24

and had been flying for both corporate

04:25

and regional operators before she was hired by UPS

04:28

as a 727 flight engineer back in 2006.

04:32

She quickly moved over to the 757 fleet

04:34

where she upgraded to first officer

04:36

and she then transitioned over to the 747

04:38

on which she stayed for a few years.

04:41

Then in 2012, she was again moved over

04:43

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

04:47

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

04:51

she had only flown around 400 hours on the Airbus

04:54

at the time of this flight.

04:56

Her training records were clean

04:58

and she was described as a top-notch person

05:00

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

05:04

But she had recently also started complaining

05:07

about the roster and how she barely

05:08

could keep her eyes open in flight sometimes.

05:12

On one occasion in March 2013,

05:14

a colleague had actually found her sitting

05:16

with her face down on a table in the crew room

05:18

complaining about being totally and completely exhausted.

05:22

Before the accident flight she had

05:23

started her shift flying one night flight

05:26

before having a further long break.

05:28

She then used that break by going visiting a friend

05:31

in Houston before on the following day going back

05:33

on a jump seat flight to San Antonio

05:35

and resuming her duty.

05:37

That duty included flying over from San Antonio

05:40

to Louisville in the late evening

05:41

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

05:44

with the captain of this story.

05:46

Now even though she had mentioned

05:48

to her husband that she had been sleeping a lot

05:50

when she was visiting her friend,

05:51

her use of personal electronic equipment showed

05:54

that she'd really hadn't gotten

05:56

that much coherent sleep there

05:58

and that pattern continued throughout

06:00

the following day and night as well.

06:02

So this meant that it is likely that the first officer

06:05

had a substantial sleep debt

06:07

when her shift with the accident captain started

06:09

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

06:14

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

06:16

around 02.30 in the morning

06:18

and started preparing their flights together.

06:20

Everything looked fine,

06:22

so they eventually just walked out the aircraft,

06:24

prepared it for departure and then took off

06:26

for their first flight over to General Downing in Peoria

06:29

and then their second to Chicago Rockford

06:31

where they had their scheduled night stop.

06:34

These flights were completely uneventful

06:36

and they ended up signing into their hotel rooms

06:38

at around 06.30 in the morning.

06:41

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

06:45

the first officer was seen having breakfast

06:47

in the hotel restaurant.

06:48

And she then was active on and off during the day

06:51

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

06:54

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

06:56

but not enough to cancel out that sleep debt

06:59

that she was now undoubtedly carrying with her.

07:02

The captain, on the other hand,

07:03

seemed to have rested properly during the night stop.

07:05

So he was in a quite good mood

07:07

as the hotel shuttle brought them out to the airport

07:09

at around 10 minutes past eight in the evening.

07:12

The duty that they had ahead of them

07:13

was what's known as a split duty

07:15

where they would be operating two flights

07:17

in the late evening followed by a few hours of rest

07:19

and then another flight in the very early morning.

07:22

They again started by going through the planning documents

07:25

which their dispatcher had prepared for them

07:27

and saw that there would be no major issues

07:29

during at least their first two flights.

07:31

They decided on fuel to take and then they walked

07:33

out of the aircraft and started it up as normal,

07:35

having no idea what was soon about to happen

07:39

and I'll tell you all about that after this:

07:42

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07:44

I could about this accident

07:45

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07:48

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07:51

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08:03

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08:48

Before they started, they had decided

08:49

that the captain would be pilot flying for the first flight

08:52

from Rockford over to Peoria

08:54

and then the first officer was going

08:55

to fly the second from Peoria over to Louisville.

08:58

Both flights went off without any problems

09:00

and when they finally landed in Louisville around midnight,

09:03

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

09:06

until it was time for their last flight

09:07

over to Birmingham-Shuttlesworth Airport.

09:10

This was plenty of time to get some shut-eye

09:13

so both pilots booked a sleep room

09:15

at the UPS facilities to try

09:16

to get the most out of the break.

09:19

Now at this point, you might be wondering

09:20

what the routines actually were at UPS for avoiding fatigue.

09:24

I've already mentioned that cargo airlines

09:26

had been exempted from the coming rule changes

09:28

regarding crew flight time limitations

09:30

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

09:34

In fact, UPS had negotiated with the unions rules

09:37

that were supposed to mitigate the threat of fatigue

09:39

and those rules were significantly stricter

09:42

than the minimum required at the time.

09:45

One super important part

09:46

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

09:50

whenever they felt that it was needed

09:51

and in that case, being taken off the roster immediately

09:54

with no questions asked.

09:56

This facility was available for all pilots,

09:59

but there were some strings attached to it.

10:02

You see UPS had put in force something known

10:05

as a sick bank where a certain amount of days

10:08

were available for each pilot every year.

10:11

A bonus on top of their regular pay

10:13

would then be paid out at the end of the year

10:15

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

10:19

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

10:21

by a dedicated manager and if it was found

10:24

that the call was made unfairly

10:26

as in if the pilot had actually had enough rest

10:28

to avoid fatigue but hadn't used it properly

10:31

well, then a day would be removed

10:32

from that pilot's sick bank.

10:35

This was supposed to work as a positive incentive

10:37

for the pilots but anyone who knows humans

10:40

knows how quickly something like that

10:42

will start to be seen as a punishment instead

10:44

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

10:47

in whatever way they could.

10:50

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

10:53

the two pilots came out of their sleep rooms

10:55

and started preparing for their final flight.

10:58

Both of them had managed to get a bit of sleep

11:00

and they now started looking through the briefing material

11:03

that their flight dispatcher had once again prepared for them.

11:06

On the weather side, they showed a weak front

11:09

that was present just north of the Birmingham area

11:11

with a low pressure gradient,

11:12

meaning that they could expect very light winds,

11:15

but also some quite low clouds at around 400 feet.

11:19

The low clouds were clearing slowly

11:20

from the south so at the time the pilots

11:22

were looking at the observations,

11:24

the cloud ceiling was variable

11:25

between 600 and 1,100 feet.

11:28

On top of this there was also

11:30

a active notice to airmen, NOTAM,

11:32

which indicated that the main runway

11:34

at the destination airport, Runway 06/24

11:37

would be closed for some work

11:38

on the runway lights between 0400 and 0500.

11:43

Now their flight was scheduled

11:44

to arrive about 10 minutes before the runway

11:46

would be reopened again so this left

11:48

only Runway 18 available for landing.

11:51

This runway was significantly shorter than the main one,

11:54

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

11:59

an ILS precision approach available to it.

12:03

Instead there was a localizer

12:04

and an RNAV GPS non-precision approach available

12:07

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

12:11

this would require an extra alternate to be filed

12:13

since it was a high likelihood

12:15

that the pilots wouldn't be able to see

12:16

the runway from the higher minimas of those approaches

12:20

The dispatcher who had been planning this flight

12:22

was well aware of this and had, therefore,

12:24

planned for Runway 18 to be used

12:26

but he didn't reach out to the crew directly

12:29

to communicate this slightly unusual circumstance.

12:32

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

12:36

if they had any questions and he didn't want

12:37

to reach out and possibly insult the captain

12:40

with the information that he thought would be obvious.

12:43

At the time the dispatchers in the US

12:44

went through annual recurrent training

12:46

to keep their planning skills high

12:48

and also something known as DRM,

12:50

Dispatchers Resource Management,

12:51

but that training never included any pilots.

12:55

If that would have been the case,

12:56

the dispatcher would have probably known

12:58

that we pilots always appreciate any help that we can get

13:01

and no operational information

13:03

would be seen as improper or insulting.

13:06

And, in fact, on this occasion it looks

13:08

like the pilots indeed missed that NOTAM

13:10

about the closed runway as some later discussions

13:13

in the cockpit will soon show.

13:15

And the fact that this whole thing

13:17

could have likely been avoided

13:18

if the flight was just operationally delayed

13:20

by about 15 minutes or so

13:22

to allow the main runway to open

13:23

is just truly, truly tragic.

13:26

In any case, the pilots now finished up

13:28

their preparation and then ordered fuel

13:30

for the short 45 minutes hop down towards Birmingham.

13:33

Since the first officer had flown the previous flight,

13:35

the captain would now be flying.

13:37

So as soon as they got out of the aircraft,

13:38

he started setting it up for departure

13:40

as the first officer did the walk-around

13:42

and checked on the cargo loading.

13:44

The aircraft they were operating

13:46

was a 10-year-old Airbus A300

13:48

powered by two enormous Pratt & Whitney 4158 turbofan engines

13:52

and it was in great condition.

13:55

The pilots had asked for 34,650 pounds of fuel

13:58

and with a cargo of 89,227 pounds.

14:01

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

14:05

below the max landing weight,

14:06

meaning that they were quite heavy this morning.

14:09

When the first officer came back into the cockpit,

14:11

the captain gave her a departure briefing

14:13

and then finished up the last part

14:14

of the pre-flight preparation and checklist.

14:17

They then had to wait a little bit

14:18

for the final cargo loading to be completed.

14:20

And during that time they chatted

14:22

a bit about how they were feeling.

14:24

The first officer mentioned that she

14:25

had been feeling so tired when the alarm went off.

14:28

And they then continued discussing the unfairness

14:30

of the fact that they, cargo pilots,

14:32

would not be included in the new flight time limitations

14:35

that were being negotiated

14:37

like if there were second class pilots or something.

14:40

Now I want to clearly point out here

14:43

that these new rules for passenger-carrying pilots

14:45

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

14:49

these pilots would have still been legal to fly

14:51

even if they had been subjected to those new rules.

14:55

The captain had only had a slightly shorter rest

14:57

than required under the new rules

14:59

a few months earlier and the first officer

15:01

was well within these new limits.

15:04

Anyway, they soon received the last pieces of paperwork

15:07

and at time 03:55, Flight 1354

15:09

requested pushback from the gate

15:11

and started moving towards their departure runway,

15:13

Runway 35 Right.

15:15

During the taxi-out the discussions in the cockpit

15:17

were professional and to the point

15:19

and at time 04:02, the captain advanced

15:22

the thrust levers in the cockpit

15:23

and the giant Airbus started accelerating down the runway.

15:28

The take-off was completely normal

15:30

and they initially climbed straight ahead

15:31

towards 5,000 feet according to their departure clearance.

15:35

They retracted the flaps and slats on schedule

15:37

and were soon handed over to the departure frequency

15:40

where the controller cleared them

15:41

to climb to 10,000 feet and to turn

15:43

onto an easterly radar heading

15:45

before finally clearing them south

15:47

down towards a VOR called BOWLING GREEN.

15:50

The first officer entered that VOR

15:52

into the flight management computer

15:53

and called out, "NAV available"

15:55

and the captain engaged the NAV mode.

15:58

Now this mode, the NAV mode,

15:59

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

16:03

You see modern aircraft generally follow

16:05

a predetermined flight plan

16:07

that have been approved by air traffic control,

16:09

long before the flight actually starts.

16:12

A part of pilot flying's preflight preparation

16:14

is to enter this flight plan

16:15

into the flight management computer

16:17

and after that, verify it carefully and then execute it

16:20

so it can be used in flights

16:22

When air traffic control then, after departure,

16:24

clears the aircraft to a specific point,

16:26

in this case the BOWLING GREEN VOR,

16:28

the pilot will just select that waypoint

16:30

at the top of the active flight plan,

16:33

verify that it looks correct

16:35

on the navigation display and then execute that routing.

16:38

Providing that the aircraft's autopilot

16:40

is then active in the NAV mode,

16:42

it will turn and follow this new routing

16:44

and after that, to whatever waypoint

16:46

that lies behind it, according to the flight plan.

16:49

Air traffic control will assume

16:50

that the aircraft is following the pre-approved flight plan

16:53

so there is no need to give any further clearances

16:55

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

16:58

And this is how air traffic control

17:00

can actually handle thousands of flights per day

17:02

because the aircrafts are basically navigating autonomously.

17:06

Now using that flight plan,

17:07

the flight management computer

17:08

will also be able to calculate when they should start

17:11

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

17:14

and as long as nothing changes,

17:16

we pilots will basically just need to ask for descent

17:20

then manage the aircraft's speed and configuration.

17:24

The navigation, both laterally and vertically

17:26

will be done perfectly by the computer.

17:29

But the FMC is not an intelligent computer

17:32

and will only do exactly what it's told.

17:36

Because of that, it is susceptible

17:37

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

17:41

meaning that if we don't program it properly,

17:43

it can start showing all sorts of wrong information

17:46

and that's worth keeping in mind.

17:49

The aircraft was eventually cleared

17:50

to climb to their cruise level of flight level 280.

17:53

And around that same time, the controller also told them

17:55

to continue straight towards Birmingham Airport.

17:59

Now this clearance would wipe out

18:00

all of the other points that the pilots had entered

18:02

into their flight plan and just replace them

18:04

with a straight line towards their destination airport.

18:08

In order to make that happen,

18:09

the first officer would have entered

18:11

the airport's ICAO identification code, KBHM,

18:15

into the FMC and then put that on top

18:17

of the legs page as the new active waypoint,

18:20

basically telling the aircraft to just fly there.

18:23

But, of course, in reality,

18:24

the aircraft wouldn't actually fly

18:26

all the way to the airport.

18:27

At some point, they would have

18:29

to break away from this direct routing

18:31

and intercept an instrument approach

18:32

into whatever runway they would use at Birmingham

18:36

and the pilots obviously knew that.

18:39

If a direct like this is entered

18:40

and nothing else is done

18:41

to crop the route into something more realistic,

18:44

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

18:47

all the way until they're overhead the airport

18:50

and then turn back out and fly

18:51

whatever approach they had planned for,

18:53

adding a lot more track miles to the route

18:56

than they would actually fly.

18:58

Like I said, it is a little bit stupid.

19:01

So the way this is normally dealt with

19:02

at least in my airline, is that the pilot monitoring

19:05

will then create a new waypoint

19:06

which is maybe 20 nautical miles short of the airport

19:09

on the direct two leg and then connect

19:11

that new waypoint with whatever approach they're expecting.

19:16

This will then obviously have to be very closely monitored

19:19

that it's not actually the clearance

19:21

they've been given, just an estimation

19:22

but it will give a far more accurate picture

19:25

of what is likely going to happen

19:26

and therefore help the FMC

19:27

to calculate a more accurate descent path.

19:30

But in this case, this was not done and neither

19:33

of the pilots noticed this discrepancy.

19:36

On the legs page in the FMC/CDU,

19:38

this issue was shown as a route discontinuity message

19:40

after the KBHM point, letting the pilots know

19:43

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

19:48

Anyway, soon after this direct routing was received,

19:50

the first officer went off-frequency

19:52

to listen to the Birmingham

19:53

Automatic Terminal Information Service, ATIS

19:55

and to write down the weather and approach information.

19:58

ATIS information Papa was active

20:00

and it said that the winds were calm,

20:02

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

20:06

and another one at 7,000 feet.

20:08

On top of that, it also informed the pilots

20:10

that the localizer for Runway 18 was in use

20:12

since Runway 06/24 was closed.

20:15

The information of the runway closure

20:17

apparently came as news to the pilots

20:19

with the captain just commenting,

20:20

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

20:23

This just showed that he probably felt

20:25

a little bit frustrated with having to fly

20:27

a much more complicated maneuver

20:28

at five o'clock in the morning.

20:31

The first officer also chimed in and pointed out

20:33

that this was typical because they were a little bit heavy

20:35

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

20:39

Again, this information had been available to them

20:42

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

20:44

they would have also known

20:45

that the main runway was scheduled

20:46

to open less than 15 minutes

20:48

after their scheduled arrival time.

20:50

Another thing that I want to point out here

20:52

is that even though the ATIS and also some EICAS messages

20:55

that the crew had received

20:56

showed a nice and high cloud base

20:58

of around 1,000 feet over the ground,

21:01

the reality was actually a bit different.

21:04

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

21:07

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

21:11

but at the time of this observation,

21:13

none of those were present exactly over the runway

21:15

where the cloud base was being measured

21:18

The meteorologist who had sent out this weather

21:21

had included this information in a special note

21:24

but because of some issues with the EICAS weather formatting,

21:27

UPS had actually stopped including those type of notes

21:30

in the weather report sent out to the aircrafts.

21:33

And the same actually went for the tower controller

21:36

who had updated the ATIS.

21:37

He could also have included

21:39

those type of side notes in the ATIS if he wanted

21:41

but there were no clear instructions on exactly what type

21:44

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

21:46

so he had just skipped it.

21:49

What that all meant was that as the captain

21:51

was now starting to prepare

21:52

for the localizer non-precision approach,

21:54

he and his colleague had likely a mental model

21:56

of the weather which was dramatically better

21:58

than what it actually was.

22:00

And that brings us to the type of approach

22:02

that they were now preparing to fly.

22:05

Like I already mentioned, it was a localizer approach

22:07

and as its name suggests,

22:09

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

22:13

The localizer is obviously one half of an ILS approach

22:16

but without the glideslope vertical guidance,

22:18

meaning that it's much more complicated to fly

22:20

and gives less guidance hence it's regarded

22:22

as a non-precision approach

22:25

In a few of my previous videos,

22:26

I've explained that non-precision instrument approaches

22:28

who are flown without vertical guidance

22:30

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

22:34

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

22:38

A constant descent will ensure a more stabilized approach

22:41

without any large changes in trim and thrust needed

22:44

to level off between the different minimum altitudes

22:46

so this was what the crew were now preparing for.

22:50

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

22:52

and carefully verifying distances versus calculated altitudes

22:56

or with the use of the vertical nav path option

22:59

where the aircraft would be flying a pre-programmed path

23:02

down to a specific altitude over the threshold.

23:04

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

23:08

He started his briefing by going

23:09

through a special non-precision approach checklist

23:12

which highlighted all the important steps

23:14

including which minimum descent altitude, MDA, to use,

23:17

in this case 1,200 feet and they then continued

23:20

with how the approach was going to be flown,

23:22

including all of the relevant points

23:24

on the instrument approach charts.

23:26

As the captain was briefing the first officer was dealing

23:28

with the radios and was soon handed over

23:30

to the Atlanta Center Controller.

23:33

This new controller told them to descend to flight level 240

23:36

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

23:40

And at the same time, a FedEx aircraft

23:42

with the same call sign number, FedEx 1354,

23:45

also appeared on the frequency

23:47

and when they heard this, both pilots mentioned

23:49

this potential threat of ATC mixing up their call signs.

23:53

This, at least to me, showed

23:54

that they were both pretty switched on at this point

23:57

and well into the game.

23:59

The captain initiated their descent at time 04:32

24:02

and when they formed the controller about this,

24:04

he did indeed mix them up with the FedEx aircraft,

24:07

which the two pilots had a little chuckle about.

24:10

All in all, the atmosphere in the cockpit

24:12

was pretty good at this point.

24:14

Next, they were handed over

24:15

to the Memphis control center where they were soon cleared

24:18

to descent further, down to 11,000 feet.

24:21

This was also read back by the first officer

24:22

and after the captain had selected this new altitude

24:25

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

24:28

Usually they kind of take you to 15

24:30

and then they hold you up high."

24:32

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

24:35

by ATC will soon become important.

24:38

Next, they were handed over

24:40

to the Atlanta Controller who gave them

24:41

the latest altimeter setting for Birmingham,

24:44

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

24:48

the captain asked for the approach checklist.

24:50

So far, this flight was flown perfectly according

24:53

to UPS standard procedures but that would soon change.

24:58

At around 04:40, the background sound

25:00

on the cockpit voice recorder could be heard decreasing,

25:03

which is a sign of the aircraft slowing down.

25:06

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

25:09

which was likely said as a reminder for the first officer

25:11

since it was actually her who should have called that.

25:14

She repeated it and then told the captain

25:16

that she would ask for lower.

25:18

What was likely going on here was

25:20

that the aircraft had been descending

25:21

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

25:25

but as they were now getting closer,

25:27

the captain started to reduce the speed

25:29

to slow the descent down

25:30

but also to reduce their kinetic energy, speed,

25:33

instead of their potential energy, altitude.

25:37

We always tend to do it this way

25:39

when we are being kept high by ATC as it will enable us

25:41

to regain the path by descending with a higher speed later

25:45

once a lower altitude clearance is received.

25:48

The first officer asked the controller for lower

25:49

to which he answered that they would need

25:51

to switch over to the Birmingham Approach Controller for that

25:55

And this type of thing, it happens all the time,

25:57

and it's super annoying to have to switch over

26:00

to another frequency and check in when you see

26:02

that you are already getting high on the approach path,

26:05

but apart from anticipating it,

26:07

there is not much more you can do.

26:10

Anyway, as soon as the first officer checked in

26:11

with the Birmingham approach,

26:13

they were immediately cleared to descend to 3,000 feet

26:15

and the controller also told them

26:17

that the main runway was still closed

26:19

and asked if they wanted to proceed for the Localizer 18.

26:23

The first officer responded, "Affirm."

26:25

And the controller then told them to turn right 10 degrees

26:28

and to join the localizer on that heading,

26:30

maintaining 3,000 feet.

26:32

Now here, a couple of crucial things happened.

26:36

First, remember what I said about the importance of having

26:38

the flight management computer updated

26:40

to make sure that the most accurate information

26:42

was always there?

26:43

Well, in this case this turn to the right

26:45

would have meant that the captain

26:47

would have selected the heading mode on the autopilot

26:49

and then turned the aircraft about 10 degrees to the right.

26:53

And since the NAV mode was now no longer used,

26:56

this would have enabled the first officer

26:58

to go into the flight management computer

26:59

and select the first point on the approach

27:01

as the active waypoint and then execute that.

27:04

She could have also extended the centerline,

27:06

which I won't go into how to do here

27:08

but both of these techniques

27:10

are referred to as sequencing the waypoints

27:12

and are absolutely crucial to do

27:14

in order to get the correct path on the coming approach.

27:18

But instead of doing that,

27:19

the first officer instead started joking

27:21

about how the controller's questions

27:22

regarding if they wanted to proceed

27:24

for the Localized Runway 18 was a little bit weird

27:27

since they didn't have much of a choice in the matter.

27:30

The captain agreed and some general amusement ensued.

27:33

But, of course, if they would have actually read

27:35

the NOTAM, they would have known

27:37

that this question was probably asked

27:38

because the main runway would open up in around 18 minutes.

27:42

In any case, this jittery conversation

27:44

meant that the waypoints in the FMC was never updated

27:47

or sequenced and the captain didn't notice it.

27:50

This in turn meant that the FMC now thought that it had

27:53

a lot more track miles than it actually had

27:56

and therefore started showing

27:57

that the aircraft was well below the profile.

28:00

But curiously, after the pilots

28:02

had stopped laughing about the ATC's silly question,

28:05

the captain now asked for gear down

28:06

and this was very early to do that.

28:10

He then remarked, "And they keep you high,"

28:13

which was followed by a few similar remarks

28:15

from the first officer.

28:16

In reality, they were not particularly high at this point.

28:19

So it's likely that already out here

28:21

the captain had actually started gaining

28:23

a faulty situation awareness of their profile.

28:26

It is possible that the fact

28:28

that the vertical profile was now showing them

28:29

as very low, was somehow misinterpreted

28:32

by the captain as being very high instead

28:35

just based on his anticipation of ATC leaving them high.

28:39

In any case, they were now descending fast

28:41

down toward 3,000 feet

28:42

and the captain had armed the localizer mode

28:44

to capture the inbound signal.

28:46

But if they would have looked closer on their navigation display

28:49

and their FMC/CDU, They would have seen

28:52

that the painted track still continued towards the airport

28:55

And that there still was a flight plan discontinuity

28:58

written on the CDU, but this didn't happen.

29:02

This was, of course, a serious omission by both of the pilots.

29:04

And this giddy attitude that they were now showing

29:07

could potentially be a sign of on-setting fatigue.

29:10

At time 04:43:24, the controller cleared

29:13

the aircraft for approach

29:14

and told them to descend to 2,500 feet to maintain

29:17

until they were established on the localizer.

29:21

The crew complied with that and only a few seconds later,

29:24

the localizer came alive and captured,

29:25

turning the aircraft towards the runway.

29:28

From this point onward, they were clear to descend

29:30

according to the minimum altitudes on the approach chart,

29:33

but that initially didn't happen.

29:36

The first charted minimum altitude was 2,300 feet

29:38

to maintain until a point called BASKN

29:40

but instead of setting that, the crew just continued

29:43

descending to their last cleared altitude, 2,500 feet,

29:47

The captain asked the first officer

29:49

to activate the approach in the FMC

29:51

if she hadn't already done so and she answered, "Okay."

29:55

You see, in the Airbus A300, you need to physically activate

29:58

the approach by selecting it in the FMC

30:00

in order for the path to become active

30:02

and the captain was likely hoping

30:03

that this would fix the issue with the strange path

30:06

that he was now seeing.

30:08

A few seconds later, the first officer had completed

30:10

the task but since the FMC points still weren't sequenced,

30:14

the vertical path deviation symbol remained pegged

30:16

at the top, indicating that there were more than full scale

30:19

or 400 feet below the path.

30:22

As they descended to 3,500 feet, the captain asked

30:25

for the slats to be extended

30:26

and he also exclaimed, "Unbelievable!"

30:29

Likely referring to what he still perceived as being kept high.

30:33

The first officer just agreed with a slight chuckle

30:35

and then she extended the slats for him.

30:38

The captain asked for flaps 15 to be extended

30:40

which the first officer also did

30:42

as they were handed over to the new approach frequency

30:44

with the same controller.

30:47

And as soon as they switched the frequency over,

30:48

the controller now cleared UPS Flight 1354

30:51

to land Runway 18 which would be

30:53

the last message to the crew.

30:56

The captain continued slowing the aircraft down

30:58

and asking for more flaps.

30:59

And at time 04:45:50, he called for flaps 40

31:03

and the landing checklist to be completed.

31:05

Just five seconds after that,

31:07

he also asked for the missed approach altitude

31:09

of 3,800 feet to be set.

31:11

And setting a new altitude was important here

31:13

because without that, he would not be able

31:15

to continue descending.

31:18

But since the missed approach altitude

31:19

was higher than their current altitude,

31:21

there would now be nothing stopping them

31:23

from descending all the way down to the ground.

31:27

The aircraft had now leveled off at 2,500 feet

31:29

and the captain must have been

31:31

expecting that the vertical path

31:32

would soon become alive

31:33

so that he could engage the path mode.

31:36

But it was still sequenced wrong

31:38

so it just continued showing maximum fly up indications

31:41

with no tendency of moving.

31:44

Around here, as they were passing overhead

31:46

the BASKN point, the captain must have understood

31:48

that something was wrong.

31:50

But instead of telling this to the first officer,

31:52

he just selected the vertical speed instead

31:54

and now started descending.

31:57

This was not what they had briefed

31:59

and he was now effectively flying

32:01

an unbriefed dive-and-drive step-down approach

32:04

instead of the briefed CDA.

32:06

He initially selected a descent of 700 feet per minute,

32:09

which would have been quite okay

32:11

but soon increased that to 1,000 feet per minute instead

32:14

whilst also still muttering about being kept high.

32:18

The first officer had now completed the landing checklist

32:20

and noticed that they were flying in vertical speed

32:23

and not in path as they briefed

32:25

so she said, "Um, let's see you're in vertical speed?

32:29

Okay."

32:30

The captain responded, "Yeah, I'm gonna do vertical speed.

32:34

Yeah, he kept us high."

32:36

All of these comments shows a captain

32:37

who was unreasonably worried

32:39

about the 200 feet above profile they actually were here.

32:43

And the fact that they actually were this high

32:45

not because of ATC but because he hadn't descended

32:48

down to the appropriate minimum altitude,

32:52

those comments just doesn't really sit right with me.

32:55

I think that it's way more likely

32:57

that he had indeed misinterpreted

32:59

the indicated vertical profile

33:01

as extremely high instead of what it actually said,

33:04

extremely low.

33:06

It's very hard to know why an experienced captain

33:09

would make such a mistake but it is possible

33:10

that the expectation bias of being kept high,

33:13

coupled with the effects of flying in the middle

33:15

of the window of circadian low could maybe be an explanation.

33:20

In any case, this misconception

33:22

was further shown when a few seconds later,

33:24

he said, "And we're like way high or higher. (chuckles)"

33:29

The first officer who obviously didn't suffer

33:31

from the same illusion responded,

33:33

"Ah, about a couple of hundred feet,"

33:36

to which the captain answered, "Yeah."

33:39

But he didn't reduce his descent rate

33:41

instead he increased it to about 1,500 feet per minute.

33:46

Now he did call out, "Uh, all right.

33:49

So at 3.3 we should be at 1,380,"

33:51

which indicated that he was monitoring

33:53

the altitude slightly here.

33:55

Located at 3.3 miles distance was the point IMTOY,

33:59

which had a 1,380 feet restriction on it

34:02

and the aircraft would be crossing

34:03

that altitude almost exactly.

34:06

After that, they would be able to descend

34:08

down to their minimum descent altitude of 1,200 feet,

34:11

which was about 600 feet over the ground.

34:14

Meanwhile, the first officer was adjusting

34:16

the missed approach altitude on the mode control panel.

34:18

And then as they passed 1,530 feet,

34:21

she correctly called out, "There is 1,000 feet.

34:24

Instrument cross-checked, no flags,"

34:26

indicating that they were now 1,000 feet above the ground.

34:30

The captain responded with, "All right.

34:32

The DA is 1,200,"

34:34

showing that he knew that this was the next hard altitude.

34:38

But do you remember what else had been reported

34:40

to be about 1,000 feet above the ground?

34:44

Yeah, the cloud base.

34:46

It is very likely that the crew

34:47

was now fully expecting to start breaking

34:49

out of the clouds and seeing the runway

34:53

but what they didn't know was that a layer of lower clouds

34:56

had now moved in over the final approach

34:58

obscuring the view down to a much lower height.

35:02

We cannot know this for sure

35:03

but it is likely that both pilots now started scanning out

35:07

through their cockpit windows looking for the runway

35:09

through the still dense clouds.

35:12

Meanwhile, the aircraft was descending

35:13

with 1,500 feet per minute, a much higher rate

35:17

than the highest vertical speed approved

35:18

for a stabilized approach below 1,000 feet.

35:21

In the UPS manuals,

35:22

it was clearly stated that 1,000 feet per minute

35:25

was the highest rate allowed

35:26

under normal unbriefed circumstances

35:28

and if the rate was higher than that,

35:30

well then a go-around was mandatory.

35:33

Anyway, next it was now up to the first officer

35:35

to call out, "Approaching minimums,"

35:37

and, "Minimums," as they approached the 1,200 feet MDA

35:40

but those calls were never made.

35:44

Instead she said, "It wouldn't happen to be actual,"

35:47

which can be interpreted as her referring

35:49

to the actual instrument meteorological conditions

35:52

they were actually inside and that would further corroborate

35:55

the idea that she was likely looking outside at this point.

35:59

Now there was an automatic call out

36:01

both for 500 feet and minimums provided by Airbus

36:05

for the A300, which if they were installed

36:07

would have made these callouts anyway

36:10

but UPS had chosen to disable that feature on their fleet.

36:14

Now, obviously, the captain was pilot flying

36:16

and therefore, in charge of managing the flight path

36:19

so when he passed the MDA with no runway in sight,

36:22

he should have gone around

36:23

or at least leveled off even without any callouts,

36:26

but that also didn't happen.

36:28

Instead the aircraft was now well below the MDA

36:31

and the correct profile and was still descending.

36:34

The captain soon called out, "Two miles,"

36:36

which strangely indicated that he must have been monitoring

36:39

at least some of his instruments here

36:42

but only 13 seconds later the GPWS system delivered

36:45

its first caution, "Sink rate."

36:48

This was almost immediately followed

36:49

by the captain mumbling, "There it is,"

36:51

indicating that he now likely saw the runway

36:53

and what he saw must have been utterly terrifying.

36:57

The aircraft was at this point at a height

36:59

of only around 250 feet over the ground,

37:01

over a mile away from the runway.

37:03

So all four PAPIs must have been glowing bright red here

37:07

indicating just how low they were.

37:10

The captain responded by immediately reducing

37:12

the vertical speed to 600 feet per minute,

37:14

which was obviously still too much and he then called out,

37:17

"Oh, I got the runway, 12 o'clock!"

37:19

To which the first officer responded,

37:21

"Got the runway in sight, eh..."

37:25

The captain now also called that he would be disconnecting

37:27

the autopilot, but it was sadly too late.

37:31

Two seconds after this, the autopilot-off warning

37:33

could be heard and this was almost immediately followed

37:35

by the first sound of impact,

37:37

as the wings and the aft part of the aircraft smashed into trees

37:41

and power lines in their path.

37:43

This was then immediately followed

37:44

by a, "Too low, terrain," GPWS warning

37:47

which came late because the aircraft

37:49

was so close to the airport at this point

37:51

that the GPWS warning envelope

37:53

had been reduced in order to avoid nuisance warnings.

37:57

The captain called out, "Oh, did I hit something?"

37:59

Immediately followed by several

38:01

even louder impact sounds as the aircraft slammed

38:04

into an earth mound about one mile prior to the threshold.

38:08

The impact severed the aircraft into several different pieces

38:11

with the cockpit and forward part being severely compressed

38:14

and the aft part almost immediately bursting into flames.

38:18

In the tower, the controller hadn't received any warnings

38:20

about the dire situation of the aircraft.

38:23

Instead, at times 04:47:41,

38:26

he could just see a huge fireball

38:28

rising towards low clouds at the far end of the airport.

38:32

And even though he saw this,

38:34

it took him over one minute to press the crash alarm

38:37

and that happened because the control screen

38:39

had a different layout between

38:41

the day shift and the night shift

38:42

and he therefore, just initially couldn't even find the button.

38:46

After that, there was some initial telephone confusion

38:49

between all of the involved rescue teams

38:51

where the rescue leader didn't even realize

38:52

that a crash had already taken place.

38:55

But that initial confusion was quickly sorted out

38:57

and the fire services rapidly reached the wreckage

39:00

but there was sadly nothing they could do.

39:04

Both pilots had perished from the pure impact forces.

39:09

The investigation concluded that the probable cause

39:11

of this accident was the pilot's continuation

39:14

of an unstabilized approach and their failure to monitor

39:17

their aircraft altitude, which led them

39:19

to descend below the minimum descent altitude

39:21

and then into terrain.

39:23

The reasons this happened included

39:25

all of the factors that I've already mentioned in this video

39:28

and the investigation led to several important recommendations,

39:31

all of which I will include on my website

39:33

to which you can find a link to below.

39:36

But the most important lessons

39:37

that came out of this included more collaborative training

39:40

around the area of fatigue, both between the regulators,

39:43

the airlines and the pilot unions.

39:46

This was to make sure that the reporting systems

39:48

and preventive measures were understood

39:50

by everyone involved and that their use

39:53

would be strictly non-punitive.

39:56

The first officer was found to have been suffering

39:57

from a big sleep debt, mostly because she hadn't utilized

40:01

her scheduled rest time in an efficient way

40:03

and this likely had a big effect on her performance.

40:06

It is hugely important that we realize

40:08

that fatigue can affect us in a very negative way

40:11

and that the responsibility for dealing with fatigue

40:14

is shared between everyone including ourselves.

40:17

Other outcomes from this included stronger calls

40:19

for making constant descent approaches mandatory

40:22

for commercial aircraft and more information sent out

40:25

to pilots about the lower GPWS warning margins

40:27

when close to an airport.

40:29

Airbus was also told to improve warnings in the cockpit

40:32

when the FMC is not properly set up

40:34

and to make those automatic call-outs standard

40:37

and not an option.

40:40

Now if you have more questions about this

40:41

or want something clarified, then please consider

40:44

joining my patreon crew, we can discuss this

40:46

directly with me in our next hangout

40:49

and there's a link that you can use to sign up

40:51

somewhere here on the screen or in the description below.

40:55

Have an absolutely fantastic day, and I'll see you next time.

40:58

Bye bye.

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Связанные теги
UPS FlightAviation SafetyPilot FatigueFlight 1354Accident InvestigationAircraft ApproachCockpit CommunicationAir Traffic ControlFatigue ManagementFlight Operations
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