UPS 1354 NTSB Investigation - CVR

[AerocatS2A]

Bloggs, I agree with your thought processes entirely, however you may be interested to know that the FCOM for at least one type (Avro RJ) recommends setting the missed approach altitude when conducting constant descent NPAs. The reason being, in part, that if the speed falls to Vmin and the speed protections kick in, the A/P automatically goes to Level Change. If a lower altitude is set in the window, the autothrottles retard and the aircraft dives whereas if a higher altitude is set, the autothrottles go to climb power and the aircraft climbs.

The downside is obvious, if you don't have the MDA set then you are in an unrestricted descent with only the pilots' awareness to keep it all safe. Normally that's good enough of course, but as in the UPS case, sometimes it's not.

[alf5071h]

olasek, #250 agreed, but my concern is that the regulators do not appear to have accepted the fact, or the NTSB based on their investigative style.
In order to keep the accident rate low – accepting current level of human performance, what safety activities should the industry concentrates on; thus perhaps the NTSB could have identified aspects or deficiencies in these.

A further concern could be that a low accident rate alone might not be sufficient to manage public awareness. Other countries might accept that aircraft accidents happen, people die (less than from other causes in their country), but the western world’s expectations, more often biased by media, might well require a reduction in the total number of events opposed to rates.
What would the public reaction have been if this accident had been a passenger flight?

Setting MDA. As above, there can be many hazards hidden in this operation depending on autoflight system design.
Some have a mini flare mode to smooth the transition before the mode change is annunciated; others might capture the altitude even after selecting GA.
A continuous descent has been shown to be safer; GA from MDA, climbing up to the pre-set alt sel.

[ironbutt57]

yah the SOP's we had on the 'bus and Boeing all called for setting go-around altitude in the window, but again we did not do dive-drive approaches...who knows what type of approach these folks were doing, as the flight plan was not sequenced, any vertical guidance from the FMC/FMGS would be unusable...once again the danger of two heads outside and nobody minding the store rears it's ugly head

[aterpster]

A reminder, the procedure being used, LOC Runway 18, had (has) a note that states, "When VGSI inop, procedure not authorized at night."

[GlobalNav]

Another reminder: the note on the approach plate about night use was noted by the NTSB and acknowledged to be an error in the document - contradicting a previously published FAA determination that Jepp did not account for.

[Mr Angry from Purley]

Ian W
There is some evidence now to suggest that Crews working night shifts "manage" rather than adapt to nights. Its likely the crew were suffering from the effects of sleepiness rather than fatigue. In a previous post it was stated the Captain had been sick prior but had managed to attend a family function for 2 days. If fatigue is a factor it doesnt all add up

[Smott999]

Early in my career (not as a pilot!) I can tell you that sometimes coming off "rest" ie a couple days of normal hours can be the worst, cos of course you stay up in daylight hrs to be w friends and family....your inner clock adjusts a bit....then you go back on a midnight shift and your biorhythms hit rock bottom when you're supposed to be awake and alert.

Awful. Can't imagine being in charge of an aircraft feeling like that.


They'd give us a month on day shift....it was 2 weeks before you felt normal...then you'd have 2 weeks feeling good, then back on mid nights and have to flip round again.

Not healthy.

[aterpster]

okc465:

How do you provide overnight parcel service if you don't fly at night?

They know when they sign the hiring papers. The pay is very good and the industry is not nearly as volatile as the pax carriers.

Plus, when they get senior there are some day flights that haul second and third day packages.

Some of them adapt to flying on the back side of the clock, some don't do so well. Those who don't commute tend to do a lot better. But, that's true for the entire industry.

As far as their international package flights go, they are no worse than U.S. pax international flights.

[Lonewolf_50]

BOAC: I firmly believe "opportunities for improvement in fatigue awareness and management among pilots and operators" is just NTSB speak to fill out the report and look good like so so many reports from AAIB and NTSB. I won't bet against you there. :sad:

[pax britanica]

Clearly I don't belong here from my nick but.....

For many years I travelled long haul and ULH on business , I felt tired in and occasionally dozed off in meetings , but I could always ask someone to repeat an issue or laugh it off, after all most of the other people at the meeting were in the same boat (another bad similie)

However you guys cant do the 'run that by me again' option can you and as well as fatigue the whole process of long or night flights does impact on your awareness and judgement. I almost built a career on untangling agreements that our lawyers proudly proclaimed -we were up 'til three am concluding this.

So I know that the freighter crews signed up to do a lot of night flying but that doesn't really mean anything because the affects are often subtle and insidious as exemplified by the remarks here about the change of pattern being worse than the long night duties themselves.

So I support the idea of some pressure on the carriers , why ?
1 I don't like to read about guys ( and girls) getting killed by what might have been a trivial oversight in a desk job, not because they are negligent but because of these subtle human factors
2. The safety record of the cargo industry is appalling compared to mainline Pax flights, how many wide body freighters have been written off in the last 5-6 years with little or no public or regulatory action - had these been pax aircraft the news impact would have been a thousand times greater,
3.I live near major airport and I would like to think I don't have one of these 'forgot to set MDA, failed to spot broken flight director, badly stowed freight incidents happen overhead my neighbour hood.
Again ,please Excuse me for butting in....

[Naali]

pb,don,t ask excuses, because You are on the right track. Many wider communities would have certain benefits ,reading these conversations. Always nice to have many opinions and backgrounds. Serves both ways, so thanks to You for telling.

[Airbubba]

The NTSB announced a Flight 1354 video on their twitter feed and at www.ntsb.gov today posted at this YouTube link:

https://t.co/s9ChXBKX06

NTSB News

The National Transportation Safety Board releases an 8-minute video that focuses on the key lessons that pilots can learn from the investigation of a UPS cargo plane crash in Birmingham, Ala., in August 2013.

Looks like they are new at this stuff, the video has already been pulled and the takedown notice says:

"NTSB Companion vide..." This video is no longer available due to a copyright claim by BostonAirborne.

Sorry about that.


While the video was up for a couple of hours it highlighted the human factors issues that lead the crew to impact with the ground on the non-precision approach.

Maybe the video usage rights were negotiated by that summer intern.

Or, did they use stock footage without attribution from BostonAirborne's rather limited porfolio? :confused:

See: https://secure.istockphoto.com/profile/bostonairborne

[tubby linton]

I saw the video and some of the cockpit footage was of a fly by wire Airbus and not a A306 which for an official video I thought was sloppy production.

The video is now back up.