UPS 1354 NTSB Investigation - CVR
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... what they hadn't catered for was poor ATC vectoring, inadequate charting of an approach, and specifically tiredness.
Having said that, they met the above, but no one would expect them to be descending at 1500fpm in an attempt to intercept the notional PAPI NPA.
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Tubby Linton:
That is not the case. The testimony was about the PAPI TCH and that pilots of heavy airplanes would have to take into consideration the PAPI indication when nearing the landing runway threshold.
The PAPI provided the necessary visual segment obstacle clearance until very close to the threshold. This is the case with many PAPI installations. Most pilots probably are using the Mark II eyeball by that point; akin to the ILS G/S and being inside the old Middle Marker.
In part of the testimony last week an FAA employee stated that the approach had never been intended for a heavy aircraft so where does that leave the FAA chart?
The PAPI provided the necessary visual segment obstacle clearance until very close to the threshold. This is the case with many PAPI installations. Most pilots probably are using the Mark II eyeball by that point; akin to the ILS G/S and being inside the old Middle Marker.
Jepp were negligent because they did not update the chart and they have admitted the mistake.
Their (well earned) rep is that their charts and plates are very good. Living up to that rep takes some doing.
That is interesting, but most likely not why the crew hit the ground.In part of the testimony last week an FAA employee stated that the approach had never been intended for a heavy aircraft so where does that leave the FAA chart?
Not sure why.
Another question is that with the larger runway closed, why was the UPS dispatcher sending that flight to that airport with an ETA before the usual runway was open?
UPS realised that they do not do a lot of NPA and produced a script to follow to fly them safely.
To me what they hadn't catered for was poor ATC vectoring, inadequate charting of an approach, and specifically tiredness.
I agree with you on the matter of the late descent. That was to me an interesting data point from the CVR transcript. Previous discussion about how fast they were coming down related to the glide path is all over the Tech Log thread.
The tiredness/fatigue/ crew rest issues are certainly within the UPS sphere of span and control, and perhaps the FAA .... "one set of rules for Airliners and Freight Haulers" may be in the offing.
Lonewolf I have only been involved as a pilot in airline operation for twenty plus years , most of them in a A306 but I will bow to your superior knowledge, whatever that may be, and withdraw from this discussion.
Last edited by tubby linton; 25th Feb 2014 at 16:03.
tubby, I am sorry to have given you offense.
Please accept my apologies.
I shall return to lurk mode as well.
Please accept my apologies.
I shall return to lurk mode as well.
Apology accepted. This accident has many strands and the data collected by the NTSB is enormous, even down to text messages and hotel key card swipes. I am still discovering new thought provoking issues within the documents publicly released and if I feel I have discovered anything that may be useful or worth debating I will again contribute.
Just thinking....
I was a lurker here for years before starting to comment. I read a lot of helpful posts, and then some idiotic ones, also. (I have also put my foot in my mouth) I learned some stuff, and one thing that has always been my opinion is that is never just 1 thing that leads to an accident.
Through all these posts on this thread and the original one, there are some basic common points.
1. The crew was a crew that met minimum standards
2. They were flying an unfamiliar approach at night
3. They were late in the descent (not all their fault)
4. They may have been very tired
5. They did not know where they were vertically, and did not monitor their descent rate. (maybe fatigue factor)
6. They did not GA at the "Sink Rate" warning, or when they were not stabilized per UPS SOP's (maybe fatigue factor)
The fact that the approach plates make the approach "legal" or not does not really matter.
The fact that the PAPI's are not set for a height 4 category airplane does not matter.
If they had flown either plate as published, and followed the PAPI when visible, there would probably have been a different outcome.
Through all these posts on this thread and the original one, there are some basic common points.
1. The crew was a crew that met minimum standards
2. They were flying an unfamiliar approach at night
3. They were late in the descent (not all their fault)
4. They may have been very tired
5. They did not know where they were vertically, and did not monitor their descent rate. (maybe fatigue factor)
6. They did not GA at the "Sink Rate" warning, or when they were not stabilized per UPS SOP's (maybe fatigue factor)
The fact that the approach plates make the approach "legal" or not does not really matter.
The fact that the PAPI's are not set for a height 4 category airplane does not matter.
If they had flown either plate as published, and followed the PAPI when visible, there would probably have been a different outcome.
Last edited by Jetdriver; 25th Feb 2014 at 20:25.
@OBD Thanks for all your insightful posts.
I have a few comments on your points:
2. Granted, and probably of a type that was relatively infrequent for them.
3. Not sure. they were cleared to 2,500 ft til established on the LOC and then could have descended to the 2,300 ft restriction for BASKN. Why they didn't I'm not sure. failure to set up PROF DES correctly might have been a factor.
4. They said they were tired, but I wonder if the record shows that they should have been. Doesn't seem like a terribly difficult duty day. I'm not judging though.
5. A big yes on that. Why I don't know. They were a bit behind the airplane and didn't seem to know it. the high descent rate might have contributed. Totally missed 3 key callouts.
6. Agreed. Below 1,000 ft HAT especially they should have gone missed approach, maybe even the more aggressive CFIT avoidance - but again they not vertically aware.
Agreed on the approach plate and PAPI issues
One more: I don't understand why they were unmindful of Minimums - where they should have established visual on the runway and incidentally the PAPI. There is some question whether the runway was indeed visible at MDA (1,200ft) and if not, of course, should go missed approach. All obvious to us after the fact, I understand, but the why is not so obvious.
I have a few comments on your points:
2. Granted, and probably of a type that was relatively infrequent for them.
3. Not sure. they were cleared to 2,500 ft til established on the LOC and then could have descended to the 2,300 ft restriction for BASKN. Why they didn't I'm not sure. failure to set up PROF DES correctly might have been a factor.
4. They said they were tired, but I wonder if the record shows that they should have been. Doesn't seem like a terribly difficult duty day. I'm not judging though.
5. A big yes on that. Why I don't know. They were a bit behind the airplane and didn't seem to know it. the high descent rate might have contributed. Totally missed 3 key callouts.
6. Agreed. Below 1,000 ft HAT especially they should have gone missed approach, maybe even the more aggressive CFIT avoidance - but again they not vertically aware.
Agreed on the approach plate and PAPI issues
One more: I don't understand why they were unmindful of Minimums - where they should have established visual on the runway and incidentally the PAPI. There is some question whether the runway was indeed visible at MDA (1,200ft) and if not, of course, should go missed approach. All obvious to us after the fact, I understand, but the why is not so obvious.
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Originally Posted by lonewolf50
A good friend of mine was a CH-46 pilot in the USMC. Currently a captain with Northwest, has been for some years.
Your bias is not justified.
Your bias is not justified.
Fatigue-Item 4
Fatigue is a funny thing. I think all of us who have flown long haul and overnight stuff have had periods during a flight when we were really alert, and periods when the eyelids just can't stay open.
I remember a 707 early morning London arrival where I was almost asleep at TOD, and very awake making an ILS to minimums with an FD-105.
It's possible this crew had a simultaneous fatigue situation, and missed a lot of things.
I remember a 707 early morning London arrival where I was almost asleep at TOD, and very awake making an ILS to minimums with an FD-105.
It's possible this crew had a simultaneous fatigue situation, and missed a lot of things.
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It all boils down in the end to needing RNP and GLS
Oh when will we ever learn? The answer is simply properly implemented RNP and GLS.
Since TWA 514 and long before,... to even before AL371, AL736 & AL737 (which gave us 25.1309), ...and still before Ed Burke and the All-Weather Flying Committee (and long before the Larry DeC, and Joe O, Wally R era, and the L1011)... we've needed REAL RNP, ....and by the '90's, needed GLS/GBAS.
It is time to finally recognize that fact, and globally implement "real" RNP and GLS (not FAA's RNP "lite"), to every jet runway end globally. Then we dump obsolete and wasteful SBAS/WAAS, LPV, NPAs, and much of TERPS, PANS-Ops, and other obsolete concepts and critera, and stop pushing stopgap faux solutions for low visibility landing accidents, reference trying to blame it on training, fatigue, experience, PAPIs, GPWS, TAWS, or the need for placebo ineffective expensive new fad EVS/SVS eye candy...
Since TWA 514 and long before,... to even before AL371, AL736 & AL737 (which gave us 25.1309), ...and still before Ed Burke and the All-Weather Flying Committee (and long before the Larry DeC, and Joe O, Wally R era, and the L1011)... we've needed REAL RNP, ....and by the '90's, needed GLS/GBAS.
It is time to finally recognize that fact, and globally implement "real" RNP and GLS (not FAA's RNP "lite"), to every jet runway end globally. Then we dump obsolete and wasteful SBAS/WAAS, LPV, NPAs, and much of TERPS, PANS-Ops, and other obsolete concepts and critera, and stop pushing stopgap faux solutions for low visibility landing accidents, reference trying to blame it on training, fatigue, experience, PAPIs, GPWS, TAWS, or the need for placebo ineffective expensive new fad EVS/SVS eye candy...
@Tom Imrich
While I'm not a believer that RNP/GLS solves all the world's ills, in this case the IAN kind of ILS-look-alike for practically all instrument approaches has merit.
This crew, like their colleagues, flew relatively very few non-precision approaches, and even though CDFA has it's merits, the kind of "roll your own" Rube Goldberg add on procedure to the NPA just begs for crew error.
If they could have selected and flown an ILS-look-alike approach for Rwy 18, the outcome might have been different. The NTSB Operations Group Report pretty well highlights the numerous operational errors and failures of this event. Doing an operation the same way they do most of them could make a huge difference.
IMHO
While I'm not a believer that RNP/GLS solves all the world's ills, in this case the IAN kind of ILS-look-alike for practically all instrument approaches has merit.
This crew, like their colleagues, flew relatively very few non-precision approaches, and even though CDFA has it's merits, the kind of "roll your own" Rube Goldberg add on procedure to the NPA just begs for crew error.
If they could have selected and flown an ILS-look-alike approach for Rwy 18, the outcome might have been different. The NTSB Operations Group Report pretty well highlights the numerous operational errors and failures of this event. Doing an operation the same way they do most of them could make a huge difference.
IMHO
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Problem with fatigue, it's often confused with being tired...one can have a reasonable nights sleep, and still be suffering from the cumulative effects of fatigue...it's a bit like hypoxia, one doesn't realise it at the onset...but the performance level drops appreciably
I certainly agree that there is no excuse for not having vertical guidance on any approach in this age of GPS...with all the facilities available it's just plain wrong to be flying outdated non-precision approaches with the exception of severe terrain issues...
I certainly agree that there is no excuse for not having vertical guidance on any approach in this age of GPS...with all the facilities available it's just plain wrong to be flying outdated non-precision approaches with the exception of severe terrain issues...
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The recurrent theme of fatigue is present in the interviews, at the public NTSB hearing and in the conversation on the CVR.
There was sparring between the union and the company in the hearing over the vetting of fatigue and sick calls and whether pilots hesitate to make the call because it will invite scrutiny.
However the captain's wife says in her interview that he was not really ill when he told the company he was sick for the first legs of the trip and then went to a weekend family social function.
The FO flew the first legs of the trip with another captain, presumably a reserve. The first layover in SAT was scheduled for over 60 hours after a less than four hour duty day according to a trip listing posted on another forum.
Three legs were flown in a nine hour duty day followed by a 15 hour layover in RFD. RFD-PIA-SDF sit in SDF for over three hours and then the leg to BHM. This final duty day was about 8 and a half hours.
It seems like the part of the trip that was flown was not unusually demanding by current U.S. standards except that it was done in the middle of the local night. And the captain's phony sick call seems to affirm the view that some of us can't be taken at our word on attendance issues.
Traditionally, if you had a good CBA (labor contract) you didn't worry too much about FAR's in rest and scheduling since your agreement would be more restrictive. Many of the work rules and contractual protections of legacy passenger airlines have disappeared from the post bankruptcy contracts. It was thought that the new rest rules imposed by the feds would force reduced duty limits without the need for further contractual concessions in return. Whether this will be the case remains to be seen in my opinion.
Should cargo pilots be included in the new FAR 117 rest rules? Or, should they have a similar FAR more tailored to their operational needs? I suspect the NTSB will weigh in on these questions from the direction of some of the testimony at the hearing.
There was sparring between the union and the company in the hearing over the vetting of fatigue and sick calls and whether pilots hesitate to make the call because it will invite scrutiny.
However the captain's wife says in her interview that he was not really ill when he told the company he was sick for the first legs of the trip and then went to a weekend family social function.
The FO flew the first legs of the trip with another captain, presumably a reserve. The first layover in SAT was scheduled for over 60 hours after a less than four hour duty day according to a trip listing posted on another forum.
Three legs were flown in a nine hour duty day followed by a 15 hour layover in RFD. RFD-PIA-SDF sit in SDF for over three hours and then the leg to BHM. This final duty day was about 8 and a half hours.
It seems like the part of the trip that was flown was not unusually demanding by current U.S. standards except that it was done in the middle of the local night. And the captain's phony sick call seems to affirm the view that some of us can't be taken at our word on attendance issues.
Traditionally, if you had a good CBA (labor contract) you didn't worry too much about FAR's in rest and scheduling since your agreement would be more restrictive. Many of the work rules and contractual protections of legacy passenger airlines have disappeared from the post bankruptcy contracts. It was thought that the new rest rules imposed by the feds would force reduced duty limits without the need for further contractual concessions in return. Whether this will be the case remains to be seen in my opinion.
Should cargo pilots be included in the new FAR 117 rest rules? Or, should they have a similar FAR more tailored to their operational needs? I suspect the NTSB will weigh in on these questions from the direction of some of the testimony at the hearing.
It all boils down in the end.....
Hi Tom
You're dead right that there are a lot of good lessons from way back being forgotten. Good to see Joe O and Larry DeC referenced!
By coincidence I was just looking up some stuff from the original OPSP in Montreal......... happy (!?!) days...
You're dead right that there are a lot of good lessons from way back being forgotten. Good to see Joe O and Larry DeC referenced!
By coincidence I was just looking up some stuff from the original OPSP in Montreal......... happy (!?!) days...
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slast:
I'm the third name Tom mentions. Larry D. and I did a fair amount of work together.
There are more issues and limitations with RNP AR than benefits. It DOES provide wonderful benefits for those who have IRUs and all the attendant redundancies, and are will to go through a vary onerous certification, training, qualification, and database maintenance process. That bar is far too high for most.
And, RNP AR, as good as it is for the very rich to get into Rifle, Colorado, it is being horribly over-implemented at air carrier airports that have perfectly good ILS.
Is to BHM, the crew was mandated to NOT leave MDA unless they had the PAPI in view and used its vertical guidance to nearing the threshold. Or, they could have held for a few minutes until the ILS runway was reopened.
Runways the like of 18 at BHM will not have a vertically guided approach with the FAA's terrain and obstacle free runway zone requirements. Those standards have become much more conservative than even 15 years ago.
Hi Tom
You're dead right that there are a lot of good lessons from way back being forgotten. Good to see Joe O and Larry DeC referenced!
By coincidence I was just looking up some stuff from the original OPSP in Montreal......... happy (!?!) days...
You're dead right that there are a lot of good lessons from way back being forgotten. Good to see Joe O and Larry DeC referenced!
By coincidence I was just looking up some stuff from the original OPSP in Montreal......... happy (!?!) days...
There are more issues and limitations with RNP AR than benefits. It DOES provide wonderful benefits for those who have IRUs and all the attendant redundancies, and are will to go through a vary onerous certification, training, qualification, and database maintenance process. That bar is far too high for most.
And, RNP AR, as good as it is for the very rich to get into Rifle, Colorado, it is being horribly over-implemented at air carrier airports that have perfectly good ILS.
Is to BHM, the crew was mandated to NOT leave MDA unless they had the PAPI in view and used its vertical guidance to nearing the threshold. Or, they could have held for a few minutes until the ILS runway was reopened.
Runways the like of 18 at BHM will not have a vertically guided approach with the FAA's terrain and obstacle free runway zone requirements. Those standards have become much more conservative than even 15 years ago.
NTSB Docket for UPS 1354 Accident
@slast
URL for NTSB Operations Group Report:
http://dms.ntsb.gov/pubdms/search/document.cfm?docID=410432&docketID=55307&mkey=87780
Also of interest for excellent presentations and visualization of the data is the Aircraft Performance Group Report:
http://dms.ntsb.gov/pubdms/search/document.cfm?docID=410478&docketID=55307&mkey=87780
URL for NTSB Operations Group Report:
http://dms.ntsb.gov/pubdms/search/document.cfm?docID=410432&docketID=55307&mkey=87780
Also of interest for excellent presentations and visualization of the data is the Aircraft Performance Group Report:
http://dms.ntsb.gov/pubdms/search/document.cfm?docID=410478&docketID=55307&mkey=87780
