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UPS 1354 NTSB Investigation - CVR

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Old 21st Feb 2014, 13:41
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The F/O had numerous glamour shots done of herself in uniform.

Just something to think about.
Why? What possible relevance does that have?
Flying was work time, off duty time was hers to do with as she wished providing she was in a fit state to fly when she reported for duty.
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Old 21st Feb 2014, 13:43
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The CVR alludes to being "at 3,3D a couple of hundred feet high"

Chasing the slope down in V/S, someone mentioned 1500 fpm(?). Regardless of all possible SOP busts, sounds like a very dangerous thing to do in a rushed environment when things are easily forgotten.

Things can go bad very quickly, when you least expect it...
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Old 21st Feb 2014, 13:48
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the differences between asiana and ups is the difference between crawling (asiana, day visual apch, perfect wx) and running a marathon (ups, non precision, night/predawn, odd terrain and low scud).

comparing the two is like comparing the B52 to the C152. Both are planes, but not too much else in common.

being deceived at night and being deceived in the daylight is one thing.

And yes, loss of instrument discipline is a problem.
Yes. And no.
From the moment they became visual they both failed to put a fully servicable aircraft safely on the runway, and if I'm not mistaken, UPS had a PAPI to help him. It even seems they had time from the first impact to try to save the aircraft, but did nothing!
Oh, did I hit (somethin')?
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Old 21st Feb 2014, 13:53
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So what? Patty Wagstaff has pictures of herself taken in uniform.


Stick to the flying aspects of the accident.
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Old 21st Feb 2014, 14:18
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Glendale:

could an ILS have been installed with much higher minimums? even with some earth moving?
They would have to level a hill with houses presently on it. And, perhaps more earth moving a bit further out.
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Old 21st Feb 2014, 15:37
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Investigation, Inquiry

The original thread on this accident appeared to have richly detailed and substantive content. More than that, a number of participants in the original Th were highly interactive - swapping back and forth with computer-based profiles, and analysis, of topography, visual profiles, and other evidently pertinent information. So also did that original Th discourse over an evidently broad range of approach flying techniques, and instrumentation and automation factors.

Question: based on what you have seen with respect to the NTSB investigatory process to date, including but not limited to the hearing yesterday, what confidence level do you hold as to whether the Board is looking at all that is relevant here, and all that may reasonably be relevant, and further that Board is understanding same? (No need to remind us that this is, of course, what NTSB is "supposed" to do.) Relatedly, should the public take any disheartening from broadcast pronouncements by former DOT Inspector General Mary S. which appear to state conclusions despite the obvious on-going nature of the Board's process?

Oh and I can't let my 'rep for colorful and/or obscure comments become languid. Therefore: head shots done of the FO have as much relevance to this Thread, the original Th, and the accident investigation, as a hot dog has relevance to a warm puppy.
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Old 21st Feb 2014, 16:20
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I'm from BHM, live there now. Learned to fly there. My house is 15 miles or less from the crash site.

When I was learning to fly in the eighties, that runway was about 5000' and bookended by large ridges. The city of Birmingham is in a long, narrow valley (it was originally called "Oxmoor Valley.")

Fifteen years ago the city's airport authority wrangled a prodigious amount of federal money and enlarged that runway. It involved moving perimeter roads, buying up houses and a Panama Canal - sized earthmoving operation.

I can't imagine enlarging that runway even more. And the real problem is the other end - the southern end. Red Mountain's there, and it ain't going no place....
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Old 21st Feb 2014, 16:22
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I watched the hearing yesterday and I have been examining the information provided in the docket. A number of things stand out for me:

1 There is no mention in the approach briefing that the weather was on or possibly below limits.

2 Descent angle of the approach. There is no mention in the brief that the angle is steeper than the usual 3 degrees and that this wll require a higher vertical speed.The initial vertical speed selected is 700fpm and they were already starting off 200ft high having maintained 2500ft The chart provides a vertical speed/ground speed box and for 140kt the v/s should be 813ft/min so a higher V/S would have been needed to to get back onto the profile.
The chart only provides one check height to monitor the vertical performance before MDA and that is only 180ft above it.

3 The DME does not indicate zero at the threshold, it reads 1.3nm, which is not discussed.

4 No mention is made of the box on the chart stating that this procedure is not authorised at night.

5 The thousand feel calls seems to occur at 1000ft amsl( only 360ft above ground)

6 The crew seem to become fixated with the task of flying the approach and calls regarding MDA are omitted.

Willow Run I think it is fairly obvious why this accident happened and I hope it is obvious to the NTSB. If they have re-run the scenario in the simulator using the CVR for a script the errors should be obvious. The question is why the errors were made , and it appears to be the usual swiss cheese of multiple factors lining up. I believe the one thing that may have saved them is having enhanced gpws fitted and I hope that the NTSB make this compulsory on all large aircraft.
The discussion of fatigue by the crew before departure is interesting . We are still in the early phase of operators taking fatigue seriously. and crew are the worst at diagnosing their own fatigue. From the testimony yesterday at UPS a fatigue report is analysed and if it is deemed to not fit the fatigue model a day is deducted from the pilot's bank of sick days.As pilots we do not all fit the same model. I cannot sleep the way I did when I was in my twenties and long duties take longer and longer to recover from.
I hope that the issue of fatigue appears in the final report and more effort is made to mitigate it. I also hope that the new FAA FTL are applied to cargo airlines.

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Old 21st Feb 2014, 16:50
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The hearing

@Tubby Thanks for getting the discussion back on the important stuff.

1. Actually there was some mention of the weather and that indeed the visibility (~10 sm) was adequate for conducting the approach.

2. The aircraft maintained 2,500 ft all the way to FAF, but could have descended to 2,300 ft once established on LOC. Why? Pilot briefed the use of PROF DES and FO said she set that up (though it seems she missed something). Would PROF, properly set up and flown been suitable for the steeper glide path angle?

4. The NA was mentioned during the hearing - but actually there is a NOTAM making the approach available at night - Jepp chart notwithstanding - so it was a legal approach.

5. The 1,000 ft call was supposed to be for 1,000 ft above touchdown - not MSL nor AGL.

6. Not obvious to me what the crew was fixated on, but the lack of verbal callouts by the FO for 500' above touchdown, 100' above minimums and Minimums seems to indicate lack of attention to the vertical situation. As does the continued high VS as they blew through minimums. AP not disconnected as they should have.

The PIC briefed PROF DES for the vertical path. FO said she set it up, but somehow missed something. There was a line of questioning about the critical steps and how obvious it would be if something was missed when setting this mode up. Many cues were mentioned, but I wonder how obvious these would be to pilots who rarely fly non precision approaches and use that mode.

Then the PIC, noting how high they were so close to the airport, chose to use VS, without briefing the change, though the FO noticed. At less than 1,000 ft above touchdown, 1,500 FPM is extreme - outside even UPS criteria for stabilized approach. Shouldn't the approach be discontinued per SOP?
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Old 21st Feb 2014, 17:16
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Just my $.02 for now

While we have generalized fatigue, and this crew seemed to have had "adequate" rest, they may have actually just been really tired. On the other hand, their conversations may have been just shop talk.

Overall, it appears to me, that they had OK lateral situational awareness, but very poor vertical SA.

I've been trying to decipher just how high and fast they were at any of the fixes. If anyone has got that, please share.

If I had a 1,500 FPM sink rate going at less than 1,000 AGL, I would seriously consider going around, and definitely would have at the "sink rate" call that close in.

Regards,

OBD
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Old 21st Feb 2014, 17:23
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I have been reading the approach set up again and it appears that the crew were reading from a written script. The atis does not mention the possibility of low cloud which appeared in the metar remarks but had not appeared in the briefing material. In my airline we always include the weather in the brief as it has a bearing on who flies and who lands (Monitored approach philosophy).
I think the crew completely missed the N/A on the chart. The majority of those posting on the subject missed it as well and we are sitting here at a pc and probably more awake than this crew.

The Captain discusses in his brief how he will discontinue the approach at various stages and then fails to execute this. The final gate was at the 3.3nm point when it was obvious that he approach was unstable but this crew continues.( I think they were about two-three hundred feet high)

As to the crew being fixated they had already been making a mental model of their rest period and the transport to the hotel before they had even dispatched. The approach was just a part of the journey back to bed and some rest before another series of night flights. They had also been discussing how much rest had been achieved before duty had commenced.
To me this is pilot shorthand for saying I am tired and I am not as sharp as I should be.

From the CVR:

"and I was out in that sleep room and when my alarm went off I mean
I'm thinkin' I'm so tired..."

I think that cargo pilots can feel aggrieved that the FAA values their safety less than a passenger pilot by not applying the new FTL to them.
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Old 21st Feb 2014, 17:27
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Wall Street Journal:

NTSB Details Pilot Errors Before 2013 UPS Cargo Jet Crash

Investigators Say UPS Pilots Deviated From Safety Rules, Approach Procedures Before Crash

By ANDY PASZTOR
Feb. 20, 2014 7:27 p.m. ET

Pilots of a United Parcel Service Inc. cargo jet repeatedly deviated from mandatory company safety rules and approach procedures just before their plane plowed into a hillside last August near the Birmingham, Ala., airport, federal investigators revealed Thursday.

The cockpit crew exceeded the maximum vertical descent rate for a stabilized approach, failed to verbalize critical altitude changes and violated basic safeguards by continuing the final phase of a descent using limited navigation aids even though the runway lights weren't visible, according to the National Transportation Safety Board.

But in delving more deeply into the causes of the Airbus A300 crash, which killed both pilots, NTSB staffers uncovered that the commander had what industry and government experts consider a history of training lapses and proficiency challenges stretching back more than a decade. The documents point to several mistakes in simulator sessions, but no accidents or enforcement actions. More broadly, that spotty record raises questions about the effectiveness of UPS pilot-training programs, especially when visual approaches replace automated descents, according to aviation-industry officials.

In 2000 and 2002, Cerea Beal, then a UPS first officer flying Boeing Co. 727 jets, voluntarily withdrew from training for promotion to captain, a highly unusual move. The NTSB didn't give a reason for the withdrawal, but government, industry and pilot union sources said that such moves, especially within two years of each other, typically avoid an outright failure. According to the NTSB, UPS told investigators it didn't retain those training records.

After working as a co-pilot from October 1990 to the spring of 2009—an unusually long stint by most aviator standards—the former military helicopter pilot became an A300 captain in June of that year, according to information released by the NTSB. About a year later, Capt. Beal was in command of a plane that veered off a taxiway after landing at Charlotte Douglas International Airport in North Carolina, the board disclosed at a hearing Thursday. NTSB documents didn't give any additional examples of incidents.

Reports, interview transcripts and other data released by the board also detail that in the days and hours leading up to the fiery accident, Capt. Beal complained about chronic fatigue. He told one fellow pilot the string of late-night and early-morning shifts was "killing" him.

During an early portion of the accident flight, the cockpit voice recorder captured co-pilot Shanda Fanning telling the captain that "when my alarm went off" following a rest break during the duty period, she was upset. "I mean, I'm thinking, 'I'm so tired,'" she recalled according to the transcript.

In one of the text messages retrieved by investigators, the day before the crash Ms. Fanning complained that she "fell asleep on every damn leg" of her various flights the previous night. But some of the fatigue may have been outside the company's purview. Before starting night duty that extended to almost 5 a.m. the morning of the crash, according to an NTSB analysis, Ms. Fanning opted to spend most of her free time outside her hotel room.

UPS has said Capt. Beal was experienced and fully qualified, adding that whatever training issues cropped up were "appropriately dealt with at the time." On Thursday, the Atlanta package carrier reiterated that its schedules are "well within FAA limits," noting that the Birmingham crew spent less than three hours of its final eight-hour duty period in the air.

The cargo airline also said its fatigue-prevention measures, including special sleep rooms and joint pilot-management reviews of schedules, are intended to ensure adequate rest.

The fatigue issue is bound to spark more debate about whether cargo pilots should have been covered by more-stringent fatigue rules recently implemented for pilots flying passengers. Some House and Senate members are pushing for such legislation. UPS, however, said the Birmingham crew's schedule complied with the latest requirements for U.S. passenger airlines.

Within hours of the hearing, the nation's largest pilots union stepped up calls for legislation to make cargo haulers comply with the same scheduling rules as passenger carriers.

"Pilots who operate in the same skies, take off from the same airports, and fly over the same terrain must be given the same opportunities for full rest, regardless of what is in the back of the plane," said Lee Moak, president of the Air Line Pilots Association.

The hearing underscored lax discipline and apparent confusion in the cockpit during roughly the final two minutes of the flight. Safety experts from UPS and Airbus testified that the crew improperly used the flight-management computer to try to set up a safe approach path. When that didn't work, they said, Capt. Beal violated UPS rules by abruptly switching to a different type of approach and then commanding the autopilot to maintain an excessively steep descent.

UPS officials testified that both of those events should have prompted pilots to initiate a go-around, or immediate climb away from the airport. Instead, the crew continued the approach below the safe altitude for making such a decision.

In addition to lapses by the crew, Thursday's hearing highlighted the limitations of outdated collision-avoidance technology aboard the aging A300. Barely seven seconds before impact, the ground-proximity warning system alerted the pilots that they were descending too rapidly.

Due to the way the system was configured, however, the NTSB said an explicit warning about the impending crash and a command to immediately pull up didn't come until a second after the initial sound of impact was captured by the cockpit recorder.

An updated warning system, recommended years ago by officials at supplier Honeywell International Inc., would have provided at least several precious seconds of additional warning. But it isn't clear whether that would have been enough to save the crew and the plane. "Maybe, maybe not," Federal Aviation Administration official Tom Chidester testified.

NTSB Chairman Deborah Hersman focused on whether average pilots understood that because of design limitations and older technology, "certain [safety] systems will be inhibited" or operate differently close to the ground.

As part of its continuing investigation, the NTSB determined that the plane's engines, flight controls and other onboard systems, including collision-warning technology, operated normally before impact.

In one email released by the board, an FAA official indicated three months after the crash that the visual navigation aids installed on the Birmingham runway weren't designed to handle planes as large as the Airbus A300.

Write to Andy Pasztor at [email protected]
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Old 21st Feb 2014, 18:06
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tubby, you are mistaken.
4 No mention is made of the box on the chart stating that this procedure is not authorised at night.
Please accept the correction that was offered to you.
Originally Posted by GlobalNav
4. The NA was mentioned during the hearing - but actually there is a NOTAM making the approach available at night - Jepp chart otwithstanding - so it was a legal approach.
This was discussed in some detail in the initial Tech Log thread, which I seem to recall your participating in. The approach plate clearly states a condition for the NA: VGSI inop. This too was discussed in the other thread.
My memory is hazy: I can't recall if the company had not authorized that approach "as is" but required a VNAV or other nav system.
Were you referring to the company rules/SOP not allowing that approach at night?
That's not the same issue as the NA on a plate.
5 The thousand feel calls seems to occur at 1000ft amsl( only 360ft above ground)
^^^This, and your point on both descent rates, and glide slope, strike me as key areas of interest. The crew (CVR transcript is the ref) seems to recognize that they are getting a late descent/are high as they get into the approach.
And this:
Capt. Beal violated UPS rules by abruptly switching to a different type of approach and then commanding the autopilot to maintain an excessively steep descent. UPS officials testified that both of those events should have prompted pilots to initiate a go-around, or immediate climb away from the airport. Instead, the crew continued the approach below the safe altitude for making such a decision.
As to this:
In one email released by the board, an FAA official indicated three months after the crash that the visual navigation aids installed on the Birmingham runway weren't designed to handle planes as large as the Airbus A300.
Can someone explain to me what is meant by that?

Last edited by Lonewolf_50; 21st Feb 2014 at 18:20.
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Old 21st Feb 2014, 18:33
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If I had a 1,500 FPM sink rate going at less than 1,000 AGL, I would seriously consider going around, and definitely would have at the "sink rate" call that close in.
According to the UPS FOM excerpts in the docket, over 1000 fpm sink at 1000 feet AGL (actually above the runway as GlobalNav points out) is a mandatory go around.

Some carriers are required to call 'stable' or 'go around' at 1000 feet, apparently UPS does not do this (yet, anyway - I'd almost bet it will be the new procedure after this crash).
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Old 21st Feb 2014, 18:46
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@Lonewolf

Quote:
In one email released by the board, an FAA official indicated three months after the crash that the visual navigation aids installed on the Birmingham runway weren't designed to handle planes as large as the Airbus A300.

Can someone explain to me what is meant by that?

The issue is that the Threshold Crossing Height (TCH) of the PAPI for Runway 18 does not meet the prescribed FAA minimum for Group 4 aircraft which includes the A300. I think the TCH happens to be 47 feet, but the prescribed value for Height Group 4 is 75 ft (+5/-15). This is addressed in the Survival Factors Group Report, beginning at page 11. FAA says that since the info is published, no NOTAM or restrictions are necessary. Its up to the operator to figure out whether and how to use it.

Actually, if I am not mistaken, the PAPI is advisory, not path guidance and certainly not all the way to touchdown. A few feet of TCH doesn't change the angle, and in the case of the accident, the crew blew right through the PAPI centerline (2 white 2 red) and even 4 red with nary a blink. So, in any case its not a contributing factor for the CFIT a mile out. IMHO
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Old 21st Feb 2014, 18:49
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Bureaucracy, and sleep

Thanks Tubby L.

Wondering still if the factually intensive discussion here & on original Th is replicated - it actually ** "should" ** be surpassed!!- by the factual work-up being done by 'TSB. I mean I'll revert to puking Grunt if after the 'TSB report comes out, Ths here find fault, missing or wrong analyses, junk like that.

One thing about the stoned-and-drunk four-striper Hollywood movie - I won't dignify that piece of barnyard dung by writing the name of the film here- got right is that 'TSB hearings are for show, and only slightly about getting testimony for the record, but not about finding the key facts. Perhaps others more knowledgeable will hold a different assessment. Point I'm trying to make is, I want to know if the techies get what this board got (continuing back-&-forths notwithstsnding) - not, not, not interested in petty bureaucrats who are impressed by tv cameras trained on them preening. About an air crash investigation or anything else

I've got to go sit for some head shots in my undergraduate uniform. I'll brief on fatigue regs sometime soon (maybe from the perimeter of the real Willow Run, the airport I mean....).
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Old 21st Feb 2014, 19:06
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Photos? Who doesn't have photos of themselves in uniform? Does the company do it for newhires? Did they have any union or company job where the pictures were taken?


Or did she just have it taken because she was proud of herself? Good for her, she should be. I've been to camera shops and seen photos displayed of guys that have formal pictures taken in their uniform. Why'd they do it? I don't know and I don't care. I doubt it makes them a weaker pilot.


Over the decades I've probably seen dozens, if not more than 100, of these pictures and there's probably thousands that I havn't seen. BFD. It's not like the camera steals your soul like some uneducated people believe.
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Old 21st Feb 2014, 19:17
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Global Nav, thank you!

Stable approach or go around: industry best practice, eh?

misd: looks like a fine photo for a resume.
Also helps me put a face to a name.
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Old 21st Feb 2014, 19:22
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I've had pictures taken in uniform. for my ID card. In 38 plus years of flying I think there have been two pictures of me in uniform. And I HAVE PAID FOR NONE OF THEM (true airline pilots understand this ;-)

someone mentioned patty wagstaff, wasn't she stopped for DUI? or something like that?


and someone responded to my views on the difference between asiaana and ups. to my recall there was a PAPI on 28 L at SFO too.

Something has been mentioned about the captain bypassing an upgrade or something. Even more about him being a helicopter pilot prior to being a pilot for UPS.

I ask this question, not trying to do anything more than ask: should helicopter time be counted towards airplane ratings/certificates of any kind?

and

should airplane time be counted toward helicopter ratings/certificates of any kind?

I guess I will say this one more time, but in a different way. An airliner should be flown with a crew. Both asiana and ups had a crew up in front.

and the crew must be watching for mistakes of the the pilots. both of them.

you must do your own required items well and you must watch the other guy and he must do his stuff well and watch you too.

the copilot could have said: EXCESSIVE RATE OF DESCENT BELOW 1000' AFE/AGL, go around

but she didn't

I have seen people who grew up at sea level always think that 1000' is 1000', u all know what I mean.

asiana, the guy in the right seat could have said: low airspeed, go around

but didn't.

is there a relationship here? maybe
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Old 21st Feb 2014, 19:41
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Apologies i meant to write that no mention was made by the crew regarding the approach was not authorised at night Box on the chart at any time during the flight. We did discuss this on this forum and the minima box stated simply not available at night without any caveat regarding vgsi.
Now imagine you have been awake for twelve plus hours , you are at your circadian low, and I ask you to justify this approach is legal whilst moving at 250 plus kt. Try and dig out the notam from 25 plus pages of briefing probably printed on a poor quality printer with a prehistoric printer ribbon and then tell your colleague why you cannot fly this approach or why you can and formulate a plan about what you are going to do.The clock is running towards your next report time for another series of night flights. Every minute in the air is a minute less sleeping . This is when rules and sop tend to drift away.
This restriction on the chart should have been formulated during the turnround and a plan produced. (Jeppesen have admitted that the notam was missed and have corrected the chart.)
The crew flew an approach which was not authorised and busted their minima.They recognised that the approach was unstable but the final gate at Imtoy was ignored. If they were that far off the profile at that point they should have gone around. This approach though as currently drawn does not have a lot of references to monitor the vertical profile. There are only two altidues published and they are at BASKN and IMTOY. Ideally you want a chart which shows range against altitude for a selection of distances.
According to the testimony the dispatcher thought they would fly the Rnav but did not want to talk down to the pilot. It is a great case of assuming and we all know what happens if you do.

I have not seen an ntsb hearing before and from this side of the pond I was quite impressed. I did notice that some specific questions and points were asked by the chairwoman to be less specific but whilst this may be for the public benefit,in private I hope that the points that participants were trying to make have been logged.
Finally, I don't care whether the FO has posed in some photographs. She is not here to defend herself and both crew members have paid with their lives for their ommisions and mistakes.
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