Fatal Error! How UPS Flight 1354 Ended in Disaster
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
😀 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.
👨✈️ 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.
🛫 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.
🚨 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.
🛬 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.
📉 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.
⚠️ 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.
🔍 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
💡Cargo pilot
💡Pilot fatigue
💡Flight time limitations
💡Non-precision approach
💡Minimum Descent Altitude (MDA)
💡Ground Proximity Warning System (GPWS)
💡Circadian low
💡Flight Management Computer (FMC)
💡Stabilized approach
💡NOTAM (Notice to Airmen)
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
- [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
and I'll tell you all about that after this:
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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.
We always tend to do it this way
when we are being kept high by ATC as it will enable us
to regain the path by descending with a higher speed later
once a lower altitude clearance is received.
The first officer asked the controller for lower
to which he answered that they would need
to switch over to the Birmingham Approach Controller for that
And this type of thing, it happens all the time,
and it's super annoying to have to switch over
to another frequency and check in when you see
that you are already getting high on the approach path,
but apart from anticipating it,
there is not much more you can do.
Anyway, as soon as the first officer checked in
with the Birmingham approach,
they were immediately cleared to descend to 3,000 feet
and the controller also told them
that the main runway was still closed
and asked if they wanted to proceed for the Localizer 18.
The first officer responded, "Affirm."
And the controller then told them to turn right 10 degrees
and to join the localizer on that heading,
maintaining 3,000 feet.
Now here, a couple of crucial things happened.
First, remember what I said about the importance of having
the flight management computer updated
to make sure that the most accurate information
was always there?
Well, in this case this turn to the right
would have meant that the captain
would have selected the heading mode on the autopilot
and then turned the aircraft about 10 degrees to the right.
And since the NAV mode was now no longer used,
this would have enabled the first officer
to go into the flight management computer
and select the first point on the approach
as the active waypoint and then execute that.
She could have also extended the centerline,
which I won't go into how to do here
but both of these techniques
are referred to as sequencing the waypoints
and are absolutely crucial to do
in order to get the correct path on the coming approach.
But instead of doing that,
the first officer instead started joking
about how the controller's questions
regarding if they wanted to proceed
for the Localized Runway 18 was a little bit weird
since they didn't have much of a choice in the matter.
The captain agreed and some general amusement ensued.
But, of course, if they would have actually read
the NOTAM, they would have known
that this question was probably asked
because the main runway would open up in around 18 minutes.
In any case, this jittery conversation
meant that the waypoints in the FMC was never updated
or sequenced and the captain didn't notice it.
This in turn meant that the FMC now thought that it had
a lot more track miles than it actually had
and therefore started showing
that the aircraft was well below the profile.
But curiously, after the pilots
had stopped laughing about the ATC's silly question,
the captain now asked for gear down
and this was very early to do that.
He then remarked, "And they keep you high,"
which was followed by a few similar remarks
from the first officer.
In reality, they were not particularly high at this point.
So it's likely that already out here
the captain had actually started gaining
a faulty situation awareness of their profile.
It is possible that the fact
that the vertical profile was now showing them
as very low, was somehow misinterpreted
by the captain as being very high instead
just based on his anticipation of ATC leaving them high.
In any case, they were now descending fast
down toward 3,000 feet
and the captain had armed the localizer mode
to capture the inbound signal.
But if they would have looked closer on their navigation display
and their FMC/CDU, They would have seen
that the painted track still continued towards the airport
And that there still was a flight plan discontinuity
written on the CDU, but this didn't happen.
This was, of course, a serious omission by both of the pilots.
And this giddy attitude that they were now showing
could potentially be a sign of on-setting fatigue.
At time 04:43:24, the controller cleared
the aircraft for approach
and told them to descend to 2,500 feet to maintain
until they were established on the localizer.
The crew complied with that and only a few seconds later,
the localizer came alive and captured,
turning the aircraft towards the runway.
From this point onward, they were clear to descend
according to the minimum altitudes on the approach chart,
but that initially didn't happen.
The first charted minimum altitude was 2,300 feet
to maintain until a point called BASKN
but instead of setting that, the crew just continued
descending to their last cleared altitude, 2,500 feet,
The captain asked the first officer
to activate the approach in the FMC
if she hadn't already done so and she answered, "Okay."
You see, in the Airbus A300, you need to physically activate
the approach by selecting it in the FMC
in order for the path to become active
and the captain was likely hoping
that this would fix the issue with the strange path
that he was now seeing.
A few seconds later, the first officer had completed
the task but since the FMC points still weren't sequenced,
the vertical path deviation symbol remained pegged
at the top, indicating that there were more than full scale
or 400 feet below the path.
As they descended to 3,500 feet, the captain asked
for the slats to be extended
and he also exclaimed, "Unbelievable!"
Likely referring to what he still perceived as being kept high.
The first officer just agreed with a slight chuckle
and then she extended the slats for him.
The captain asked for flaps 15 to be extended
which the first officer also did
as they were handed over to the new approach frequency
with the same controller.
And as soon as they switched the frequency over,
the controller now cleared UPS Flight 1354
to land Runway 18 which would be
the last message to the crew.
The captain continued slowing the aircraft down
and asking for more flaps.
And at time 04:45:50, he called for flaps 40
and the landing checklist to be completed.
Just five seconds after that,
he also asked for the missed approach altitude
of 3,800 feet to be set.
And setting a new altitude was important here
because without that, he would not be able
to continue descending.
But since the missed approach altitude
was higher than their current altitude,
there would now be nothing stopping them
from descending all the way down to the ground.
The aircraft had now leveled off at 2,500 feet
and the captain must have been
expecting that the vertical path
would soon become alive
so that he could engage the path mode.
But it was still sequenced wrong
so it just continued showing maximum fly up indications
with no tendency of moving.
Around here, as they were passing overhead
the BASKN point, the captain must have understood
that something was wrong.
But instead of telling this to the first officer,
he just selected the vertical speed instead
and now started descending.
This was not what they had briefed
and he was now effectively flying
an unbriefed dive-and-drive step-down approach
instead of the briefed CDA.
He initially selected a descent of 700 feet per minute,
which would have been quite okay
but soon increased that to 1,000 feet per minute instead
whilst also still muttering about being kept high.
The first officer had now completed the landing checklist
and noticed that they were flying in vertical speed
and not in path as they briefed
so she said, "Um, let's see you're in vertical speed?
Okay."
The captain responded, "Yeah, I'm gonna do vertical speed.
Yeah, he kept us high."
All of these comments shows a captain
who was unreasonably worried
about the 200 feet above profile they actually were here.
And the fact that they actually were this high
not because of ATC but because he hadn't descended
down to the appropriate minimum altitude,
those comments just doesn't really sit right with me.
I think that it's way more likely
that he had indeed misinterpreted
the indicated vertical profile
as extremely high instead of what it actually said,
extremely low.
It's very hard to know why an experienced captain
would make such a mistake but it is possible
that the expectation bias of being kept high,
coupled with the effects of flying in the middle
of the window of circadian low could maybe be an explanation.
In any case, this misconception
was further shown when a few seconds later,
he said, "And we're like way high or higher. (chuckles)"
The first officer who obviously didn't suffer
from the same illusion responded,
"Ah, about a couple of hundred feet,"
to which the captain answered, "Yeah."
But he didn't reduce his descent rate
instead he increased it to about 1,500 feet per minute.
Now he did call out, "Uh, all right.
So at 3.3 we should be at 1,380,"
which indicated that he was monitoring
the altitude slightly here.
Located at 3.3 miles distance was the point IMTOY,
which had a 1,380 feet restriction on it
and the aircraft would be crossing
that altitude almost exactly.
After that, they would be able to descend
down to their minimum descent altitude of 1,200 feet,
which was about 600 feet over the ground.
Meanwhile, the first officer was adjusting
the missed approach altitude on the mode control panel.
And then as they passed 1,530 feet,
she correctly called out, "There is 1,000 feet.
Instrument cross-checked, no flags,"
indicating that they were now 1,000 feet above the ground.
The captain responded with, "All right.
The DA is 1,200,"
showing that he knew that this was the next hard altitude.
But do you remember what else had been reported
to be about 1,000 feet above the ground?
Yeah, the cloud base.
It is very likely that the crew
was now fully expecting to start breaking
out of the clouds and seeing the runway
but what they didn't know was that a layer of lower clouds
had now moved in over the final approach
obscuring the view down to a much lower height.
We cannot know this for sure
but it is likely that both pilots now started scanning out
through their cockpit windows looking for the runway
through the still dense clouds.
Meanwhile, the aircraft was descending
with 1,500 feet per minute, a much higher rate
than the highest vertical speed approved
for a stabilized approach below 1,000 feet.
In the UPS manuals,
it was clearly stated that 1,000 feet per minute
was the highest rate allowed
under normal unbriefed circumstances
and if the rate was higher than that,
well then a go-around was mandatory.
Anyway, next it was now up to the first officer
to call out, "Approaching minimums,"
and, "Minimums," as they approached the 1,200 feet MDA
but those calls were never made.
Instead she said, "It wouldn't happen to be actual,"
which can be interpreted as her referring
to the actual instrument meteorological conditions
they were actually inside and that would further corroborate
the idea that she was likely looking outside at this point.
Now there was an automatic call out
both for 500 feet and minimums provided by Airbus
for the A300, which if they were installed
would have made these callouts anyway
but UPS had chosen to disable that feature on their fleet.
Now, obviously, the captain was pilot flying
and therefore, in charge of managing the flight path
so when he passed the MDA with no runway in sight,
he should have gone around
or at least leveled off even without any callouts,
but that also didn't happen.
Instead the aircraft was now well below the MDA
and the correct profile and was still descending.
The captain soon called out, "Two miles,"
which strangely indicated that he must have been monitoring
at least some of his instruments here
but only 13 seconds later the GPWS system delivered
its first caution, "Sink rate."
This was almost immediately followed
by the captain mumbling, "There it is,"
indicating that he now likely saw the runway
and what he saw must have been utterly terrifying.
The aircraft was at this point at a height
of only around 250 feet over the ground,
over a mile away from the runway.
So all four PAPIs must have been glowing bright red here
indicating just how low they were.
The captain responded by immediately reducing
the vertical speed to 600 feet per minute,
which was obviously still too much and he then called out,
"Oh, I got the runway, 12 o'clock!"
To which the first officer responded,
"Got the runway in sight, eh..."
The captain now also called that he would be disconnecting
the autopilot, but it was sadly too late.
Two seconds after this, the autopilot-off warning
could be heard and this was almost immediately followed
by the first sound of impact,
as the wings and the aft part of the aircraft smashed into trees
and power lines in their path.
This was then immediately followed
by a, "Too low, terrain," GPWS warning
which came late because the aircraft
was so close to the airport at this point
that the GPWS warning envelope
had been reduced in order to avoid nuisance warnings.
The captain called out, "Oh, did I hit something?"
Immediately followed by several
even louder impact sounds as the aircraft slammed
into an earth mound about one mile prior to the threshold.
The impact severed the aircraft into several different pieces
with the cockpit and forward part being severely compressed
and the aft part almost immediately bursting into flames.
In the tower, the controller hadn't received any warnings
about the dire situation of the aircraft.
Instead, at times 04:47:41,
he could just see a huge fireball
rising towards low clouds at the far end of the airport.
And even though he saw this,
it took him over one minute to press the crash alarm
and that happened because the control screen
had a different layout between
the day shift and the night shift
and he therefore, just initially couldn't even find the button.
After that, there was some initial telephone confusion
between all of the involved rescue teams
where the rescue leader didn't even realize
that a crash had already taken place.
But that initial confusion was quickly sorted out
and the fire services rapidly reached the wreckage
but there was sadly nothing they could do.
Both pilots had perished from the pure impact forces.
The investigation concluded that the probable cause
of this accident was the pilot's continuation
of an unstabilized approach and their failure to monitor
their aircraft altitude, which led them
to descend below the minimum descent altitude
and then into terrain.
The reasons this happened included
all of the factors that I've already mentioned in this video
and the investigation led to several important recommendations,
all of which I will include on my website
to which you can find a link to below.
But the most important lessons
that came out of this included more collaborative training
around the area of fatigue, both between the regulators,
the airlines and the pilot unions.
This was to make sure that the reporting systems
and preventive measures were understood
by everyone involved and that their use
would be strictly non-punitive.
The first officer was found to have been suffering
from a big sleep debt, mostly because she hadn't utilized
her scheduled rest time in an efficient way
and this likely had a big effect on her performance.
It is hugely important that we realize
that fatigue can affect us in a very negative way
and that the responsibility for dealing with fatigue
is shared between everyone including ourselves.
Other outcomes from this included stronger calls
for making constant descent approaches mandatory
for commercial aircraft and more information sent out
to pilots about the lower GPWS warning margins
when close to an airport.
Airbus was also told to improve warnings in the cockpit
when the FMC is not properly set up
and to make those automatic call-outs standard
and not an option.
Now if you have more questions about this
or want something clarified, then please consider
joining my patreon crew, we can discuss this
directly with me in our next hangout
and there's a link that you can use to sign up
somewhere here on the screen or in the description below.
Have an absolutely fantastic day, and I'll see you next time.
Bye bye.
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