UPS 1354 NTSB Investigation - CVR [Archive]

Airbubba

21st Feb 2014, 04:49

From the original thread that has somehow ended up over on Tech Log:

The captain tried to upgrade from first officer twice unsuccessfully in 2002 before finally making it on the third try in 2009. He also somehow failed homestudy training three times in 1991 and 1992 and failed recurrent FO sim training in 2007. He failed his CFI ride in 1985. This would be unusual for most of the pilot group in my experience.

http://www.pprune.org/tech-log/521370-ups-cargo-crash-near-birmingham-al-52.html#post8330120

See: http://dms.ntsb.gov/public%2F55000-55499%2F55307%2F550065.pdf

Mention of crew training issues was conspicuously absent from the NTSB hearing. Also, the captain's military background as an aviator would normally be documented in an NTSB docket in my experience.

It could be argued that lower standards are accepted for night freight operations, indeed the accident crew makes this assertion concerning rest rules on the CVR.

Also, I would observe that industry training standards were lowered in the 1990's, sometimes inconsistently and egregiously, to embrace a broader demographic in the wake of the landmark United Airlines EEOC settlement.

Written tests were dumbed down or abolished and systems knowledge was de-emphasized to reach out to those with less technical background and ability. Interview sim rides were switched to general aviation trainers (e.g. the Frasca at United) so that people with experience flying large planes would not have an undue advantage in the hiring process.

It has been observed that we are very quick to comment here on cultural and training issues here when an Asian crew flies a perfectly good aircraft into the ground. However, when a U.S. crew does it we tiptoe around our own cultural taboos in my view.

Would better training standards help prevent accidents like the BHM crash? Should multiple training failures be discussed along with fatigue and other human factors issues when analyzing causes of the mishap?

I wonder if these questions will be addressed in the final NTSB report.

nitpicker330

21st Feb 2014, 07:15

One word------chilling :(

ManaAdaSystem

21st Feb 2014, 08:14

A night flight, but otherwise you could substitute UPS with Korean.
Same same. ****ty workmanship.

ironbutt57

21st Feb 2014, 09:42

@Mana Ada...yup pretty much....no vertical situational awareness....need to check alt vs distance..it's published on the charts..possible they penetrated a small cloud layer shortly after sighting the "runway" and kept her going down, still believing they were above profile...either way...sloppy task sharing...but it was assumed, not briefed...would be interesting to see what UPS SOP's are regarding task sharing on a non-precision approach..especially after PF calls "runway in sight"

flyboyike

21st Feb 2014, 11:15

The F/O had numerous glamour shots done of herself in uniform.

Just something to think about.

ManaAdaSystem

21st Feb 2014, 12:12

Why? Either she was qualified, or she was not.
Do freight companies accept a lower standard from their pilots than pax airlines?

Hotel Tango

21st Feb 2014, 12:20

The F/O had numerous glamour shots done of herself in uniform.

Just something to think about.

Oh come on now :ugh: :mad: That is a disgraceful thing to say. I do hope the mods remove your post asap.

glendalegoon

21st Feb 2014, 13:00

flyboyike

21st Feb 2014, 13:14

Oh come on now That is a disgraceful thing to say. I do hope the mods remove your post asap.

It's a statement of fact, a fact, I might add, she made no secret of, so I fail to see the disgrace.

aterpster

21st Feb 2014, 13:18

flyboykite:

The F/O had numerous glamour shots done of herself in uniform.

Just something to think about.

I just did. Good for her.

What possibly could be wrong with that? Does being an attractive woman mean a woman (any woman) would be a less able pilot?

Lonewolf_50

21st Feb 2014, 13:26

The F/O had numerous glamour shots done of herself in uniform.
What has that to do with airmanship? :confused:

One word------chilling :(
Indeed. :uhoh:

DX Wombat

21st Feb 2014, 13:41

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.

172_driver

21st Feb 2014, 13:43

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...

ManaAdaSystem

21st Feb 2014, 13:48

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')?

misd-agin

21st Feb 2014, 13:53

So what? Patty Wagstaff has pictures of herself taken in uniform.

Stick to the flying aspects of the accident.

aterpster

21st Feb 2014, 14:18

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.

WillowRun 6-3

21st Feb 2014, 15:37

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. :ugh:

Huck

21st Feb 2014, 16:20

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....

tubby linton

21st Feb 2014, 16:22

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.

GlobalNav

21st Feb 2014, 16:50

@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?

Old Boeing Driver

21st Feb 2014, 17:16

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

tubby linton

21st Feb 2014, 17:23

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.

Huck

21st Feb 2014, 17:27

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]

Lonewolf_50

21st Feb 2014, 18:06

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.
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?

Airbubba

21st Feb 2014, 18:33

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).

GlobalNav

21st Feb 2014, 18:46

@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

WillowRun 6-3

21st Feb 2014, 18:49

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....).

misd-agin

21st Feb 2014, 19:06

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.

Lonewolf_50

21st Feb 2014, 19:17

Global Nav, thank you!

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

misd: looks like a fine photo for a resume (data:image/jpeg;base64,/9j/4AAQSkZJRgABAQAAAQABAAD/2wCEAAkGBxQSEhQUEhQUFRQXFRUUFBQUFxUUFBQVFBcXFhQUFBQYHSggGBol HBUUITEhJSkrLi4uFx8zODMsNygtLiwBCgoKDg0OGxAQGywkHyQsLCwsLCws LCwsLCwsLCwsLCwsLCwsLCwsLCwsLCwsLCwsLCwsLCwsLiwsLCwsKywsN//AABEIARMAtwMBIgACEQEDEQH/xAAcAAACAgMBAQAAAAAAAAAAAAAAAQIDBAUGBwj/xABDEAACAQIEAgYHBgMGBgMAAAABAgADEQQSITEFQQYiUWFxkQcTMoGhscEj QlJy0fAUM+FTgpKistI0YnODwuIXJEP/xAAZAQEAAwEBAAAAAAAAAAAAAAAAAQIDBAX/xAAtEQEAAgIBAwMBBgcAAAAAAAAAAQIDESEEEjEiQVGRM0JhcYGxBRMUFSMy of/aAAwDAQACEQMRAD8A8vhCE2YiAhAQGBCMR3kJAEIwY7QFaQIloWIrAqtGBLL RBZIiFgCRJhIZYECNZKPJGw0kCMiTLLSJElCuEkwkYBAwhISiYQMUCcIQkoA jBhGDISjeMCAnpPo96I4XiODqCpmSvTqm1VCcxRlGUMCMpW4bykTOkxG3nAl 1GmzbAnwBPynXdMehL8NRKmem4dyi7lxoWBIYW2HISfQLo9T4hUdMRiKiFVB SmrC7jXMRmuLDTQDnKzbjbSKOeocGr1GslJ2Nix6p0Ci5JvsAJi1sJUXVkYD tysB5z3fiXBsNw/h+LNCmqk0HVmOruSuVczbnU7CeB0cXVpfy6lRLW9h2X5GRWbT5LREK7i/KMCbA9JMQ1hVZKw/DWp06g87Zh43kf4qhU9pGot207vTJ70Y5l9xPhL8q8MS0VpmnBPbMtqifjpn OBbXUDVT3MBMZRJNK5JllmWNhBpQy8pC0ucaytoRKlpGWSJElRGEZEUhKJhA wgTJgBC0LSUHljAjEJCU6S38NzOv9H).
Also helps me put a face to a name. :(

glendalegoon

21st Feb 2014, 19:22

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

tubby linton

21st Feb 2014, 19:41

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.

mm43

21st Feb 2014, 19:53

Here is a graphic that wasn't added to the original thread, as it was effectively "conjecture" at that time - 20130903, but I suspect the flight path indicated will be very close to the fact.

http://oi62.tinypic.com/117zl09.jpg

Below is an updated graphic of the approach profile using the integrated accelerometer altitudes from the NTSB Aircraft Performance Study included with the UPS1354 docket. The altitudes fit well with the Google Earth terrain data, which includes the treetop heights as drawn.

http://oi58.tinypic.com/fazdl3.jpg

porterhouse

21st Feb 2014, 20:00

Maybe somebody with a lot more experience than I have could help me understand how this accident happened. I am brain fried on this oneCertainly not the first and last accident which is hard to understand.
I am an astute student of aviation accidents (both big and small crafts) and one thing I learned a very long time ago there is no shortage of most bizarre screw-ups pilots are capable of pulling off. This one frankly doesn't even make the "10 strangest" list.

tubby linton

21st Feb 2014, 20:04

For a monitored approach the pilot flying the approach has his head in and the pilot landing had his head out looking for the runway There is no mention of either pilot spotting the papi on the cvr or any rad alt call outs.

Lonewolf_50

21st Feb 2014, 20:07

Tubby:
(From a few posts up, your post begins with apologies).
Key point number 1: late let down to approach. Crew is aware that they are in catch up mode for the approach they were cleared for, and we see comments to that effect in the CVR transcript.
Key point number 2: approach not stable by 1000 feet, per various well stated points in other posts.
Key point number 3: go around decision not made.
From your last post:
There is no mention of either pilot spotting the papi on the cvr or any rad alt call outs.
Data points suggesting that the crew was behind the aircraft.
=================
Flyboyike: what the heck is wrong about trying to look your best in a photograph?
Not everyone is photogenic.
It is quite possible (my wife runs into this alot) that you have a lot of photos taken of you that look "not right" and only a very few that "look right."
Maybe she'd run into the problem my wife runs into, and decided to go to a professional to get a picutre that looked nice.
You are being uncharitable, at best. :=

Not everyone, me included, is as photogenic as Ms Wagstaff.

flyboyike

21st Feb 2014, 20:44

F/Os aren't qualified to fly? That's a new one.

Sunnyjohn

21st Feb 2014, 20:47

As always with accidents, lots of holes in the cheese but, AFAIR, no-one has yet mentioned:
The circadian rhythm makes people’s desire for sleep strongest between midnight and dawn, and to a lesser extent in mid afternoon. In one study, researchers instructed a group of people to try to stay awake for 24 hours. Not surprisingly, many slipped into naps despite their best efforts not to. When the investigators plotted the times when unplanned naps occurred, they found peaks between 2 a.m. and 4 a.m.
The accident happened at 04.47.

tubby linton

21st Feb 2014, 20:54

In the testimony it is mentioned that the F/O fell asleep on every sector of her previous nights work.

Old Boeing Driver

21st Feb 2014, 20:56

Are you referring to the NA for night ops on the approach plate.

I think this was covered back on the old thread, and the NA was incorrect.

See aterpster's #340 on the thread under tech log.

There were quite a few other posts on this, but I didn't want to look through the 1,000 plus posts.

Cheers,

OBD

Edit: I found your comments, as well as others in the #450-460 post range on the old thread. I understand what you are saying.

Old Boeing Driver

21st Feb 2014, 21:01

One of the things that has puzzled me since the CVR release is why nobody called the PAPI or REILS in sight.

Having landed on that runway at night (a long time ago), it seems that they would have surely seen 4 reds.

Regards,

OBD

tubby linton

21st Feb 2014, 21:27

OBD yes we go back to the N/A box on the chart. And we have discussed it , but the crew do not mention it nor justiify their decision to fly the approach based upon the notam. Was the notam even included in their briefing pack and it was issued months before? I am trying to make the point that if I woke you up in the middle of the night and showed you the chart , would you
A notice the N/A box and B think that there was a notam telling you to disregard it?Jepp are to blame for not changing the chart but we as posters on pprune all missed it. The dispatcher is alleged to have noticed which is why he thought the crew would fly the rnav approach but he failed to bring this to the crew's attention. If there was such an ambiguity should UPS not have issued a notice alerting their crews and requested a correction from Jeppesen. They should have banned operations to the runway using that approach until the matter had been cleared up.In flight operations you should plan that your z list team will always end up trying to land at the most challenging airport despite your best efforts to send them elsewhere and do the best to keep them alive.
What I did not gather from the hearing yesterday was when the crew planned this part of their duty. It was a multi sector night so did they receive the paperwork at the start of the evening, when you would hope that they would have been at their sharpest or on the turnround prior to their last sector? Was it given to them in a well lit office with a set of charts available or on the flight deck. The A300 cockpit isn't particularly well lit and I and my coleagues often struggle to complete a manual loadsheet in the gloom so reading a multi page briefing when you are tired is going to be difficult.

xcitation

21st Feb 2014, 22:51

@OBD

One of the things that has puzzled me since the CVR release is why nobody called the PAPI or REILS in sight.

Having landed on that runway at night (a long time ago), it seems that they would have surely seen 4 reds.

Good point.
Assuming the previous graphic is indication of actual events:
PAPI could have been visible initially and then disappear at around 9000' onwards being obscured by the hill and low altitude,
The entire runway should have gradually disappeared as they drop behind the hill.
The EGPWS gave them less than 5 seconds to pull out/TOGA.
Very tragic.

Old Boeing Driver

21st Feb 2014, 23:48

Tubby. Good points. I also don't understand why the dispatcher did not speak directly to the crew at any time.

Back in the "old days" we actually talked things over and agreed to things.

He was fairly new at UPS, but a very experienced dispatcher from Atlas.

Cheers,

OBD

Old Boeing Driver

22nd Feb 2014, 00:32

I believe we agree that the 1,000 foot call is at 1,000 feet above the airport, or about 1,600 MSL in this case.

If you look at mm43's graph, her call was at 1,000 feet on the altimeter. (MSL)

Tubby mentioned this in one of his posts.

They didn't realize where they were vertically.

Has they reacted with a go around at the first "sink rate" announcement, things might be different.

Regards,

OBD

GBV

22nd Feb 2014, 02:06

From the CVR transcript, the 1000ft call was done at 4:47:02,9, comparing with the FDR that would be about 1500ft or just above 1000ft on radio altimeter. Also, they call visual at 4:47:27.9 about 150ft radio altitude or just above 900ft. They went below MDA not having the runway in sight, the "hundred above" and "minimum" calls would have saved the day as usual.

Interesting enough there is some talk about the MDA when they are approaching and passing 1200ft:

"Alright ah DA is twelve ah hundred"

"Twelve hundred yeah..."

"two miles"

"it wouldn't happen to be actual [chuckle] (they were passing 1100ft at this point)

Do you guys believe they would have intentionally descended below MDA not being visual?

Airbubba

22nd Feb 2014, 02:49

It appears the possible requirement for 1000 feet per minute down at the FAF to catch the profile was part of the canned briefing read by the PF:

04:25:47.0 HOT-1

and in the last note. select profile and verify P descent on an ILS
glideslope out approaches or localizer approaches when the VNAV
path crosses the final approach fix below the FAF minimum altitude.
start a one thousand feet per minute descent at the FAF and
immediately select profile mode to capture the path.

Would this possibly apply in the LOC 18 or does the path automatically cross BASKIN at 2300 as depicted on the chart? Some Boeings have an autothrottle surge that can occur on a computed VNAV path descent due to slight discrepancies between the calculations and charted crossing restrictions.

Does it look like they missed the fact that they could descend down to 2300 from 2500 when established on the localizer inbound to BASKIN? If they were at 3000 eleven miles from Baskin they should have been able to cross BASKIN at 2300 easily since COLIG is on profile 8.1 miles before BASKIN at 3500.

Playing catchup from above in a widebody is no fun on an ILS, harder on a non-precision since you need to be fully configured and on speed prior to the FAF on most aircraft.

It's been quite a while since I've flown an A306, would there be path guidance out to COLIG if the FO had sequenced the approach correctly? Could the crew capture the profile prior to BASKIN? Would there be guidance but no capture with a discontinuity in the box before the approach?

Should the crew have briefed a D-DA of 1250 instead of a DA of 1200? That one may depend on UPS Ops Specs for the A300.

Showbo

22nd Feb 2014, 06:07

Airbubba:

Would this possibly apply in the LOC 18 or does the path automatically cross BASKIN at 2300 as depicted on the chart?

No, it doesn't apply to the LOC 18, it only applies to the circumstances in your quote. Based on what they said, I suspect the crew were a little hazy about this.

Does it look like they missed the fact that they could descend down to 2300 from 2500 when established on the localizer inbound to BASKIN?

Yes, I think so. Moreover, they could have stayed at 2500 and captured the path from there provided they made sure they didn't cross BASKN below 2300 but they didn't seem to appreciate that and the cvr chatter seems to indicate mild annoyance that they were fed in 200 ft high and that they thought they would have to drive down to the path from above using Vertical Speed mode to capture it. Note where they say.......

...yeah I'm gonna do vertical speed.
yeah he kept us high.
kept ya high. could never get it over to profile (we didn't) do it like that. uh uh I know

We've all seen it in the sim, especially in initial training, where we've forgotten something, and the "Football" path indicator doesn't appear, and the path doesn't capture and we think, "What the .....??" I rather suspect the captain thought the reason was because of the "high" feed in and that he thought he was well above the path and that is why he continued to drive down in VS. All the while, the real reason the path never appeared was because the box hadn't been sequenced correctly. Quite why all the other subsequent opportunities to abandon the approach were missed remains to be seen.

would there be path guidance out to COLIG if the FO had sequenced the approach correctly?

In theory, yes, although the "football" is not visible unless you are quite close to the path (within 200 ft I think), somewhat like an ILS in full scale deflection. The box actually constructs a glidepath at (in this case) 3.28 degrees backwards from the TCH all the way out to infinity. In theory you can capture it anywhere once Final Approach Mode has been activated and Profile has been armed. In practice, ATC and TERPS restrictions prevent this from happening.

Could the crew capture the profile prior to BASKIN?

Yes.

Would there be guidance but no capture with a discontinuity in the box before the approach?

No..... There would be no guidance and no capture.

Should the crew have briefed a D-DA of 1250 instead of a DA of 1200? That one may depend on UPS Ops Specs for the A300.

A 1200 ft DA was correct.

BOAC

22nd Feb 2014, 08:04

I cannot recall if this was in the original thread (now in Tech Log), but the puzzle over the 'no PAPIs' call may be that the PAPIs were never in sight due to cloud/vis such that when they 'saw' the runway it would be the far end and the PAPIs were already below the sight line?

ManaAdaSystem

22nd Feb 2014, 10:22

Airbubba

22nd Feb 2014, 10:35

Thanks for your answers to my questions Showbo, I really appreciate your analysis.

The last time I trained in Toulouse, the Concorde sim was still down the hall.

I rather suspect the captain thought the reason was because of the "high" feed in and that he thought he was well above the path and that is why he continued to drive down in VS. All the while, the real reason the path never appeared was because the box hadn't been sequenced correctly.

Would the football be pegged at the bottom in this case or would path guidance not be displayed at all? It seems that the scale and 9999's were on the screen at some point from the panel questioning.

A lot of the questions in the hearing derive from issues raised in the interview summaries in the accident docket.

The 'technique' of putting something lower than the MDA on the approach page of the FMC seems to be mentioned repeatedly in the pilot interviews. If this was done it would explain why the autopilot was still on below MDA in the accident.

Desert185

22nd Feb 2014, 10:45

Good Points
Tubby. Good points. I also don't understand why the dispatcher did not speak directly to the crew at any time.

Back in the "old days" we actually talked things over and agreed to things.

He was fairly new at UPS, but a very experienced dispatcher from Atlas.

UPS dispatch provides the flight paperwork one hour before departure for domestic and 1 1/2 hours before departure for international in a briefing area. There is no personal contact with dispatchers. Keep in mind that there is a significant number of flights departing Louisville within just a few hours. It would be impossible for a dispatcher to give a face to face brief to every crew. If anything, the paperwork is overly cluttered with details not directly relevant to the flight, at least it was before I retired.

JammedStab

22nd Feb 2014, 12:56

I would like to apologise for comparing this crew with the Korean crew in SFO. I just read the transcript and thought this was a night visual gone bad, when in fact it was a non precision IFR gone bad. A world of difference from a day visual.

The three biggest holes in the Swiss cheeese when it comes to CFIT are:
-Night/darkness
-Non precision
-Terrain

Add what appears to be a weak captain and a FO who did not take proper rest prior to the flight... I'm not impressed, but it is not comparable to Korean.
Correct, in the San Francisco Asiana accident, the pilots failed to do what is required for your first solo. That is, being capable of monitoring your airspeed and make proper corrections.

However, after reading the CVR release, I am reminded of the Korean Air crash in Guam. It was different circumstances but still much closer than the SFO thing.

glendalegoon

22nd Feb 2014, 13:26

manaAda system

thanks for realizing the difference between the two.

MAY I OFFER THIS as to the screwup which caused this crash?

IF the captain thought he was high, he would be looking for a papi which showed him high, not low.

BUT WHAT IF he saw something that looked like a HIGH PAPI? Something NOT on the airport?

What if it was something like a car backup light? Or something else.

Being programmed to see something showing you high, might make you look at something OTHER than the real PAPI. And perhaps we will not know as the vehicle may never be there again(where ever THERE was).

Again if you are doing an instrument approach to minimums or below basic VFR all callouts should be bmade and one person is inside monitoring the approach.

misd-agin

22nd Feb 2014, 14:00

Information available to flight crew about their flight segment without having to contact dispatch is light years ahead of where it was 10 yrs ago. Internet based wx displays, etc.

Not unusual for dispatch to not release a flight in the computer system if he wants to talk with the Captain. No flight plan available requires a call to dispatch and after direct contact the flight plan is released.

aterpster

22nd Feb 2014, 15:43

GlobalNav:

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

In this case, use of the PAPI was mandated by the regulatory note on the approach chart. Without having the PAPI in view descent from MDA was illegal at night. This seems to have been lost on the NTSB.

Showbo

22nd Feb 2014, 16:55

Airbubba:

A lot of your questions are covered in the Operational Factors report here:

http://dms.ntsb.gov/public%2F55000%2D55499%2F55307%2F550741%2Epdf

Would the football be pegged at the bottom in this case or would path guidance not be displayed at all? It seems that the scale and 9999's were on the screen at some point from the panel questioning.

Look at page 57 of the report. They reproduced various situations in the sim and photographed what the displays look like. The un sequenced box situation shows half the football pegged at full scale high. I was trying to remember if it was even visible, I thought it wasn't, but apparently it is. Maybe I'm thinking that it's useless until active, so I ignore it. I think what you're asking is..... If the approach was incorrectly sequenced, but the path/football came active on the display, could he have used V/S to fly down it like you can do on an uncoupled ILS g/p ? The answer is no. The active waypoint in the box was KBHM. I'm not sure the box would even attempt to construct a g/p from a fix that isn't a runway.

The 'technique' of putting something lower than the MDA on the approach page of the FMC seems to be mentioned repeatedly in the pilot interviews. If this was done it would explain why the autopilot was still on below MDA in the accident.

Putting the MDA in the approach page tells the box when to disconnect the autopilot (50 ft below the MDA). Also, until you've entered the numbers, there are no cues in the box to allow you to activate the approach. I didn't see anything in the cvr that suggested they put anything other than 1200 in there. The autopilot would disconnect at 1150 ft IF they are on a captured path, in profile, on a properly sequenced approach. They weren't. Profile was armed but had nothing to capture and the plane was in vertical speed. The autopilot was never going to disconnect until someone manually disconnected it, which apparently he did, just before impact.

tubby linton

22nd Feb 2014, 19:02

Aquadalte FPA cannot be flown through the autopilot in an A306. You can choose to display the bird and the cage but the controlling F/D or A/P mode will be something else.

Capt Groper

22nd Feb 2014, 19:45

Having read all the comments, the NTSB and CVR reports I can only conclude that the crew were unfamiliar in flying a localiser approach and combined with a challenging Airport were totally unaware of the threats (terrain, lighting, approach path angle, etc).

Pilots in a well regulated IFR / ATC environment have the luxury of ATC guidance to intercept a glide slope. When that glide slope is inop/unavailable then things can go horribly wrong very quickly for the less than prepared pilots, (this is my interpretation of this accident). The answer could be more training in flying non ILS approaches in recurrent simulator and to challenging airports, not the standard home base IFR recurrent training.

ATQP proficiency checks would have identified this crew to be below standard, in all competences.

kinteafrokunta

22nd Feb 2014, 20:18

Cut to the chase...are they (the UPS pilots )more competent or more blameworthy than the OZ214 pilots?:ugh:

Airbubba

22nd Feb 2014, 20:32

Look at page 57 of the report. They reproduced various situations in the sim and photographed what the displays look like.

It makes more sense now. Like the accident FO and many of us here, I've flown both Boeings and Airbuses of this era. And, in the heat of battle I've certainly botched an approach or two. I've always been able to catch the error and fix it or go around.

The FO had also flown 767's and B-744's from her type ratings and the factual report. On many FMS's in those planes the waypoints will automatically sequence if you don't extend off the final approach fix. Also, you get path guidance that you can chase with V/S even if you forget to reset minimums in the MCP altitude window prior to the FAF.

Putting the MDA in the approach page tells the box when to disconnect the autopilot (50 ft below the MDA). Also, until you've entered the numbers, there are no cues in the box to allow you to activate the approach. I didn't see anything in the cvr that suggested they put anything other than 1200 in there.

The question of what would you put in the approach page MDA box was asked repeatedly in the pilot interviews. From what you say it wouldn't matter if the path is never captured in Profile, the box would never see the entered value to disconnect the autopilot.

Thanks again.

tubby linton

22nd Feb 2014, 21:17

The autopilot was in V/S and consequently would not disconnect at or below MDA. V/S and HDG are the most basic Flight director modes on this bus and for those with long memories an Air Inter A320 V/s ed itself into the ground many years ago near Strasbourg

Desert185

22nd Feb 2014, 21:36

Cut to the chase...are they (the UPS pilots )more competent or more blameworthy than the OZ214 pilots?

Actually, I think those two crews had something in common. Automation dependency and a further deterioration of skills that perhaps were not strong to begin with. Sound familiar?

parabellum

22nd Feb 2014, 22:14

should helicopter time be counted towards airplane ratings/certificates of any kind?
Generally 'Yes'.

The helicopter pilot has a very healthy respect for the proximity of mother earth, has developed a high degree of coordination with the controls, hands and feet always on and is, at all times, aware that his blades are doing about Mach0.73 and what will happen if they hit anything. Hundreds of helicopter pilots have successfully transferred to fixed wing, (I'm one!).

1500 to 2000 hours of helicopter flying is, to me, far more valuable than the same time flying as P2, on long haul, in the RHS, at FL350, monitoring radios and running a fuel plot.

In the case of this accident, from the record of the captain, it is possible that he had basic competency problems, unrelated to rotary wing flying.

glendalegoon

22nd Feb 2014, 23:25

I really think that helicopter time shouldn't count.

But you make some good points. But the same can be said (for most) for flight instructors, crop dusters, pipeline patrol, air racers (reno).

Does anyone have the backgrounds on both pilots in this crash?

At this time I would like to put a complete end to any talk about the pictures of the copilot. Many outside of our profession would probably like a posed picture of a loved one in their uniform. So, let's drop it. It probably isn't an ego thing. So again, including me, let's drop it.

But the concern of situational awareness being thrown out upon the runway in sight call is concerning.

Desert185

22nd Feb 2014, 23:41

The captain was a Marine Corps helo pilot.

Lonewolf_50

24th Feb 2014, 14:26

OBD yes we go back to the N/A box on the chart. And we have discussed it , but the crew do not mention it nor justiify their decision to fly the approach based upon the notam.
Tubby, if you go to the FAA approved approach plate, and if the VGSI is NOT notammed inop, then you don't need to address NA. If the VGSI were notammed INOP, then you'd need to account for the NA.

There was other discussion in tech log about a company rule on such approaches, however ...

Lonewolf_50

24th Feb 2014, 14:29

I really think that helicopter time shouldn't count.

But you make some good points. But the same can be said (for most) for flight instructors, crop dusters, pipeline patrol, air racers (reno).

That would make you mistaken.

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.

tubby linton

24th Feb 2014, 14:38

Lonewolf the crew were using the Jepp chart so whatever appeared on any other chart is irrelevant.

GlobalNav

24th Feb 2014, 15:28

@mm43 The Graph

Graphs can be very compelling and illuminating. In this case, though, I'd suggest getting on the NTSB public docket and pulling down the FDR data. Unless, I am mistaken, the aircraft was very close to the 1,380 ft MSL at IMTOY, amazingly, after they started down from BASKN (FAF) at 2,500 ft - about 200 ft higher than the restriction. Trouble is, they continued down unabated through IMTOY and then through the 1200 ft MDA at approximately 1,500 FPM.

glendalegoon

24th Feb 2014, 19:43

lonewolf

I've flown with many former helicopter pilots at my 'line. 25 years ago the sim partner I had was a former USMC helo guy. He had a bit more problem than some.

But I understand your bias. Just wanted you to know I've seen them in action. And that it wasn't just blind.

Lonewolf_50

24th Feb 2014, 20:17

tubby, we have thrashed this out in the Tech Log thread previously, and strictly speaking, since the Jepp chart was in error, as has been discussed, and the FAA chart was not, your choice to resurrect that rant is not understood.

Glen.
On second thought, never mind.

mm43

25th Feb 2014, 08:51

... what they hadn't catered for was poor ATC vectoring, inadequate charting of an approach, and specifically tiredness.The "specifically tiredness" also applies to ATC, so in that respect any laxity in ensuring vectors and assigned altitudes at way-points were adhered to, adds to the mess. By that I mean if they had been vectored to the FAF and at BASKIN advised to be at or no lower at IMTOY than 1380' - "If NOT visual with the PAPI", this accident would not have happened. The MDA of 1200' would then just be the 'back-up'.

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.

aterpster

25th Feb 2014, 12:44

Tubby Linton:

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?

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.

Lonewolf_50

25th Feb 2014, 13:48

Lonewolf on an airliner
Tubby, we went through all this in the other thread.
Not interested in your hamsterwheel, particularly as regards causes of the accident. I disagree with you that the approach was not flyable by a professional crew. The issue of a non stable approach not being waved off/gone around ... this isn't the only case where that has ended in tears.
Jepp were negligent because they did not update the chart and they have admitted the mistake.
Lovely mea culpa, after the fact. :p 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?
In re that question, aterpster has the answer. You once again seem not to be following along with this discussion regarding selected items of fact. :confused:
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.
This case suggests to me that UPS may need some work on that script, and training related to same.
To me what they hadn't catered for was poor ATC vectoring, inadequate charting of an approach, and specifically tiredness.
UPS has no control over the charting of the approach.
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.

tubby linton

25th Feb 2014, 14:31

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.

Lonewolf_50

25th Feb 2014, 16:24

tubby, I am sorry to have given you offense.

Please accept my apologies.

I shall return to lurk mode as well.

tubby linton

25th Feb 2014, 16:59

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.

Old Boeing Driver

25th Feb 2014, 19:34

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.

GlobalNav

25th Feb 2014, 20:01

@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.

flyboyike

25th Feb 2014, 20:26

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.

I don't think anyone is currently a Captain with Northwest. I could be wrong though.

Old Boeing Driver

25th Feb 2014, 20:41

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.

7478ti

27th Feb 2014, 00:39

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...

glendalegoon

27th Feb 2014, 01:17

Fatigue

we may recall the DC8 that crashed at Gitmo.

microsleep

old boeing driver may be right

GlobalNav

27th Feb 2014, 02:08

@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

ironbutt57

27th Feb 2014, 03:44

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...

Airbubba

27th Feb 2014, 08:41

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.

slast

27th Feb 2014, 09:08

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...

slast

27th Feb 2014, 13:41

@GlobalNAv

Could you point me to a reference/source for the "NTSB Operations Group Report" you refer to please?

aterpster

27th Feb 2014, 13:50

slast:

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...

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.

GlobalNav

27th Feb 2014, 15:02

@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

Lonewolf_50

27th Feb 2014, 15:20

I don't think anyone is currently a Captain with Northwest. I could be wrong though.
Good point, forgot about the merge. :eek:

slast

27th Feb 2014, 19:44

@globalnav
Thank you very much

Airbubba

28th Feb 2014, 01:57

Well, there are former Blue Angels flying cargo, and you can talk to quite a few fine aviators who did not get a thumbs up when they interviewed, so I do not agree with your United law suit version of this view of training failures. It might very well be that, although, unusual, he saw a spanking new 757 training program and thought it not up to standards for his ability to jump from 727 right seat to 757 left seat.

Not sure I follow what you are trying to say but if you know any of them Blue Angel cargo pilots, ask them about their former skipper DC who had his customary 'personal training issues' flying night freight, resigned and went to Coca Cola's flight department in the entry level position of Chief Pilot (actual title: Manager, Aviation Programs). Is this perhaps who you are talking about in the 727 and 757?

And yes, like United a few years before, Coke was under an EEOC monitored lawsuit settlement to 'promote diversity in hiring':

COCA-COLA SETTLES RACIAL BIAS CASE - NYTimes.com (http://www.nytimes.com/2000/11/17/business/coca-cola-settles-racial-bias-case.html?pagewanted=all)

I do feel that EEOC lawsuit settlements like those at UAL and Coke have dramatically influenced hiring standards, for some folks at least, in years past. Maybe I'm wrong or being judgmental but that's my view. Obviously, many other factors affect hiring standards and the forever 'coming pilot shortage' may further drop requirements to absolute mins.

The poor training history, both before and after being hired, of RS in one of the FedEx MEM Mad Dog crashes was met with calls from the NTSB for better remedial training. However, after the BUF Colgan crash, hiring standards seem to be under NTSB scrutiny as well.

In fairness to the BHM 1354 crew, due to the strong corporate commitment to recruit underrepresented demographics, they were quite possibly hired with significantly less experience than many of their classmates. This might account for some of the captain's difficulties in training years ago. He reportedly had little multiengine fixed wing time when hired at UPS, and what multi time he had was in a Shorts SD-30.

Also, the recent assessments of both crewmembers presented in the docket interviews were glowing. They were both warm, professional and wonderful people by these accounts.

mm43

28th Feb 2014, 02:08

The approach profile graphic in page #3 (http://www.pprune.org/rumours-news/534519-ups-1354-ntsb-investigation-cvr-3.html#post8332284) has a new updated graphic added beneath it.

ironbutt57

28th Feb 2014, 03:39

Yes the second profile appears to be more accurate...I was having problems with the first one, because it shows them above profile above IMTOY, which would have not been possible given their rate of descent from 2500'....

GlobalNav

28th Feb 2014, 18:32

@jstflyin

When the Captain said "and we're like way high" (4;46:53.7) the aircraft was actually above (~135ft) the nominal flight path, though characterized by the Captain as "about ... a couple hundred feet" (4:46:57.1).

When the FO called "thousand feet instruments cross checked no flags" (4:47:02.9) the aircraft was about 60 ft above the nominal flight path.

However, as we all know, at 1,000 ft above touchdown the VS was about 1,500 FPM, when the UPS maximum VS below 1,000 ft for a Stabilized Approach is 1,000 FPM.

The high VS persisted long through MDA 1,200 ft MSL (or DA if you will) (with no Minimums call), and through the required, but not called 500 ft above touchdown, until after the Sink Rate alert at around 200+ ft RA and 1000 ft MSL.

Too bad there were no automatic callouts, though I am not absolutely convinced the crew would have recognized the situation, even then.

Also too bad, in my opinion, that VS mode past FAF, though not preferred by UPS, is even permitted. The AP remained engaged in this basic mode until practically the last few seconds of flight, much below MDA.

aterpster

28th Feb 2014, 21:41

GlobalNav:

The AP remained engaged in this basic mode until practically the last few seconds of flight, much below MDA.

As well as a couple hundred feet below the PAPI slope at point of impact. Red lights only.

Showbo

1st Mar 2014, 03:55

"As well as a couple hundred feet below the PAPI slope at point of impact. Red lights only."

Take a look at Document 42 ATC 3 - Attachment 1 - BAA - ATC Airport Emergency Operating Procedures Letter of Agreement Filing Date December 16, 2013 4 page(s) of Image (PDF or TIFF) 0 Photos (http://dms.ntsb.gov/pubdms/search/document.cfm?docID=410478&docketID=55307&mkey=87780)

Open it up and look at Figure 9b on page 47.

They popped out of the cloud base about the same time they were hearing "Sink Rate!" Less than 4 secs later the captain said he had the runway in sight but from about then onwards, the 4 reds of the PAPI were obscured by terrain. Precious little time to make sense of it.

BOAC

1st Mar 2014, 06:55

Red lights only. - I think you mean 'NO lights'? Look at mm's diagram?

aterpster

1st Mar 2014, 13:03

They may have never seen the PAPIs because of weather obscuring their ability to see them. But, they had a sight line to the PAPIs until very near the end when the small hill and perhaps trees would have blocked the sight line.

Nonetheless sighting of the PAPIs was required before they departed MDA, which this crew apparently didn't understand.

Showbo

1st Mar 2014, 16:46

They may have never seen the PAPIs because of weather obscuring their ability to see them. But, they had a sight line to the PAPIs until very near the end when the small hill and perhaps trees would have blocked the sight line.

Reference....
http://dms.ntsb.gov/public%2F55000%2D55499%2F55307%2F550789%2Epdf
....."Aircraft Performance Study" pages 24 and 25.....

It is of interest to know whether the PAPI lights would have been visible to the crew of flight 1354 as it approached runway 18, and if so, what light pattern would have been perceived. This problem amounts to knowing the position of the airplane relative to each of the four PAPI light beams, and identifying whether any obstructions (such as terrain) penetrated the line of sight between the PAPI and the airplane. The angle of these beams relative to the runway are defined by the (actual) PAPI glide path angle, and the (actual) aiming angles of each of the beams relative to the glide path angle.
PAPI beam solutions for both the design value of the PAPI glide path angle (3.20°), and the nominal aiming angles for a height group 3 PAPI are depicted in Figure 9 (per Table 7, the actual aiming angles are all within 0.5 minutes of arc of the nominal values, so the beam
paths depicted in Figure 9 are representative). The altitudes of the beams depicted in Figure 9 take into account the curvature of the Earth, which will increase the height of the beams as the distance from the PAPI increases, compared to the height obtained assuming a flat Earth.
Figure 9 indicates that prior to IMTOY, flight 1354 was above the PAPI glide path, and crossed below it about 0.1 nmi north of IMTOY, though at IMTOY, the PAPI display to the crew would still have been 2 white and 2 red lights (indicating on the glide path). The display would have changed to 3 red lights and 1 white light about 0.05 nmi south of IMTOY, indicating that the airplane was deviating below the glide path. The PAPI display would have changed to 4 red lights (indicating a position well below the flight path) about 0.3 nmi south of IMTOY, or about 1.7 nmi north of the runway threshold. Of course, the video analysis described in Section D-VI indicates that at this point the runway (and PAPI) would still have been obscured by clouds, and would remain so at least until the airplane descended below 1000 ft. MSL, about 1.4 nmi north of the threshold.
When the crew reported the runway in sight at about 900 ft. MSL and about 1.24 nmi north of the threshold, Figures 9 and 24 suggest that the PAPI would have been visible for less than a second, becoming obscured by terrain almost immediately.

.....and pages 29 and 30....

As noted in Section D-VII, non-precision approach procedures specify how the airplane is to descend on the final approach course to the Minimum Descent Altitude (MDA), which in this case is 1200 ft. MSL. To descend from the MDA, the crew must have the airport / runway environment in sight, and complete the descent and landing visually. However, the security video analysis described in Section D-VI indicates that the airplane was not below the clouds (and the runway would not have been visible from the cockpit) until about 1000 ft. MSL, 200 ft. below the MDA. This finding is consistent with the crew’s reporting the airport in sight at about 900 ft. MSL.
Furthermore, the PAPI visibility analysis described in Section D-VII indicates that when the crew reported the runway in sight at about 900 ft. MSL and about 1.24 nmi north of the threshold, the PAPI would have been visible for less than a second, becoming obscured by terrain almost immediately. Consequently, it is likely that the crew never saw or recognized the PAPI lights, which could have alerted them to the airplane’s dangerously low altitude.

aterpster:
Nonetheless sighting of the PAPIs was required before they departed MDA, which this crew apparently didn't understand.

Correct...... but I seriously doubt the NTSB will ever conclude that the crew didn't understand this. Nor that they didn't know they were supposed to sequence the FMC and "extend" the approach; nor that they didn't know that the autopilot was supposed to be disconnected by 50 ft below the MDA; nor that they didn't understand that 1500 fpm at 1000 ft afe is an unstable approach requiring a go around; nor that they thought the "minimums" and 500 ft callouts were optional. The question will be, what human factors caused them to make all these omissions?

aterpster

1st Mar 2014, 23:03

showbo:

Correct...... but I seriously doubt the NTSB will ever conclude that the crew didn't understand this. Nor that they didn't know they were supposed to sequence the FMC and "extend" the approach; nor that they didn't know that the autopilot was supposed to be disconnected by 50 ft below the MDA; nor that they didn't understand that 1500 fpm at 1000 ft afe is an unstable approach requiring a go around; nor that they thought the "minimums" and 500 ft callouts were optional. The question will be, what human factors caused them to make all these omissions?

I don't believe there is sufficient information to conclude that the crew didn't understand the PAPI requirement. But, their actions make it reasonable to conclude that they disregarded this and the other visual cues requirements of FAR 91.175. Similar reasoning applies to the other omissions you cite.

GlobalNav

1st Mar 2014, 23:46

No particular reason to think the crew didn't know the visual requirements, per se, but pretty clear they were unaware of their vertical situation. I say this based on no calls for 500 ft, approaching minimums and minimums.

Most of the approaches they flew were to 200 ft DA at 700 FPM, this one to 560 HAA at 1500 FPM, so things were happening faster than they are used to. The VS mode is no help with awareness. No automatic call outs, yet AP coupled and the crew missed their required calls. They apparently didn't even look for visual cues until the sink rate alert. Behind the airplane.

Showbo

2nd Mar 2014, 01:01

No particular reason to think the crew didn't know the visual requirements, per SE, but pretty clear they were unaware of their vertical situation. I say this based on no calls for 500 ft, approaching minimums and minimums.

....... and not verifying the step down altitude at IMTOY too.

Most of the approaches they flew were to 200 ft DA at 700 FPM, this one to 560 HAA at 1500 FPM, so things were happening faster than they are used to. The VS mode is no help with awareness. No automatic call outs, yet AP coupled and the crew missed their required calls. They apparently didn't even look for visual cues until the sink rate alert. Behind the airplane.

I agree completely. But bear in mind that the sink rate alert and their emergence from cloud occurred pretty much simultaneously. See Table 9, pages 28 and 29 from http://dms.ntsb.gov/public%2F55000%2D55499%2F55307%2F550789%2Epdf

aterpster

2nd Mar 2014, 01:08

GlobalNav:

No particular reason to think the crew didn't know the visual requirements, per SE, but pretty clear they were unaware of their vertical situation. I say this based on no calls for 500 ft, approaching minimums and minimums.

Plus, they descended below MDA in clear violation of regs.

Most of the approaches they flew were to 200 ft DA at 700 FPM, this one to 560 HAA at 1500 FPM, so things were happening faster than they are used to. The VS mode is no help with awareness. No automatic call outs, yet AP coupled and the crew missed their required calls. They apparently didn't even look for visual cues until the sink rate alert. Behind the airplane.

All true. Makes them (late) children of the magenta line.

GlobalNav

2nd Mar 2014, 02:20

@aterpster. Agreed. They descended through minimums unknowingly, I surmise, and hence did not comply with the requirements. I would think they were knowledgable of the requirements though.

I find it hard not to believe that this crew is not very unique from their fleet mates and perhaps many experienced ATP pilots of the day. Lots of flight time, same training program etc. So even if this event is considered an outlier, the vulnerability to such events is not unique to a few pilots.

What allows this chain of events to happen and how can we reduce this vulnerability? I will offer up some thoughts, not because I think they are waterproof (might have said fool proof).

1. Non precision approaches, in spite of CDFA, are flown so infrequently that the level of proficiency and safety just is not equivalent to precision approaches. Therefore, we should equip aircraft with avionics that allow approaches and pilot procedures to instrument runways be as similar to ILS approaches as possible.

2. Provide Automatic call outs for key vertical milestones as a safety net to momentary lack of crew awareness. At least a call out for approaching minimums and minimums, I suggest.

3. Operators should reinforce and mandate the use of Stabilized. Approach criteria, and take away any ambiguity about pilot action in such cases. An unstable approach is a failed approach and should be aborted. It would be preferable that there be an automatic call out for 1,000 ft above touchdown which is point at which a stabilized approach must be verified.

4. It seems to me that the crew response to the Sink Rate alert was less than aggressive. Below 1,000 ft above touchdown every EGPWS/TAWS alert should be considered evidence of an unstable approach and the approach aborted. For Too Low Terrain alert, if it occurs, an aggressive CFIT avoidance maneuver.

Perhaps my suggestions are considered extreme. I think when unanticipated alerts like these occur there is a moment of disbelief and a too lengthy period of assessment and verification of the condition which can delay and diminish the commitment to a positive intervention. So take the wishy washy ambiguity out of the required response.

mm43

2nd Mar 2014, 06:17

@GlobalNav,

I have the feeling after looking carefully at the PF's control column graphic, that for about 10 secs prior to the "Sink Rate" warning the trace is looking "relaxed". The reaction time was close to 3 secs and initially in the wrong direction. Could be a "micro-nap" got in the way??

Henri737

2nd Mar 2014, 07:52

Quote from GlobalNav:

Perhaps my suggestions are considered extreme. I think when unanticipated alerts like these occur there is a moment of disbelief and a too lengthy period of assessment and verification of the condition which can delay and diminish the commitment to a positive intervention. So take the wishy washy ambiguity out of the required response.

Pretty much SOP in our company, so no, not so extreme as you might think.

GlobalNav

2nd Mar 2014, 14:29

@mm43. Not sure what you are reading into the trace, but they were still AP coupled so I'd think the yoke forces would be pretty relaxed.

I wonder at the pilot's response to the sink rate alert. Twist MCP knob to reduce VS. Way low, yet still on AP and not a very positive/aggressive reaction. Can't say for sure, but I suppose not aware how low they were, and thought a mere VS correction was sufficient.

Showbo

2nd Mar 2014, 14:41

mm43

that for about 10 secs prior to the "Sink Rate" warning the trace is looking "relaxed".

But the autopilot was still on until 7 seconds AFTER the Sink Rate warning. That's not to say that micro sleep wasn't a distinct possibility because there was a lot of stuff not happening that should have been.

aterpster

2nd Mar 2014, 16:08

Global Nav:

1. Non precision approaches, in spite of CDFA, are flown so infrequently that the level of proficiency and safety just is not equivalent to precision approaches. Therefore, we should equip aircraft with avionics that allow approaches and pilot procedures to instrument runways be as similar to ILS approaches as possible.

They probably were already so equipped had the elected the RNAV IAP to Runway 18 with a Baro VNAV advisory path.

I know the small airplane SBAS navigators provide an advisory SBAS generated advisory vertical path for the RNAV Runway 18. That, and PAPI, makes it a safe approach.

In any case runways like this one should have a tailored air carrier briefing page for Part 121 operators.

The dispatcher didn't do a sterling job either.

akwood00

3rd Mar 2014, 13:52

aterpster, What do you mean the "dispatcher didn't do a sterling job either"?

I've read your posts in this thread and you metioned various procedures and FAR's you feel the flight crew disregarded.

So after watching the NTSB hearing and reading the entire docket, how can you conclude that the dispatcher failed in any of his required FAR 121 duties?

aterpster

3rd Mar 2014, 14:18

akwood00:

aterpster, What do you mean the "dispatcher didn't do a sterling job either"?

So after watching the NTSB hearing and reading the entire docket, how can you conclude that the dispatcher failed in any of his required FAR 121 duties?

As you correctly quote me I said the dispatcher didn't do a sterling job. I did not state that the dispatcher violated any section of Part 121.

That's for the FAA to decide. I am much more conversant with regulations that apply to pilots than I am those that apply to dispatchers.

If my recollections are correct, the dispatcher planned on the flight using the LOC 18 approach, but did not communicate that to the crew.

Had the dispatcher properly reviewed the Jeppesen LOC 18 chart he would have noted that is was (incorrectly) not authorized night minimums. He should have advised the crew of this. Or, he should have made the effort to find the NOTAM that stated night minimums were authorized but only with the use of the PAPI.

His technical part of dispatching the flight should have included a better familiarity with the hazards associated with Runway 18.

He could have suggested the RNAV Runway 18 approach instead of concluding the LOC 18 would be used.

All in all, a minimum level of service at best.

akwood00

3rd Mar 2014, 15:34

aterpster:

Your recollections are not correct and you lose all credibility when you make untrue statements. Your ridiculous post also shows that you are clueless when it comes to Part 121 Operations.

Please review the docket and come back to us when you have something constructive to say.

GlobalNav

3rd Mar 2014, 15:37

@aterpster Chapter 3 of the Operational Factors Group report addresses the Accident Dispatcher

Portion quoted that relates to the planned approach:
"The dispatcher told NTSB Staff he was aware of the NOTAM closing runway 6/24, and had planned on the flight to land on runway 18.
The dispatcher also told NTSB Staff that he reviewed the localizer approach to runway 18 at KBHM prior to dispatching UPS1354 using the Jeppesen E-link to view the approach chart, and determined that the localizer approach to runway 18 was not legal due to the note in the minimums section of the chart stating the approach was not authorized at night.
The dispatcher further told NTSB Staff the RNAV approach was available to the crew, and that was the legal basis for him dispatching the flight to BHM, and there was nothing in the paperwork advising the crew that there was only one approach available to them."

Elsewhere, the dispatcher is quoted as saying he felt it would be an insult to the pilots' professionalism to point out the issue with the LOC 18. I recall him repeating that in testimony at the hearing on Feb 20.

Should we consider this is a contributing factor in the accident? The approach is in fact legal, ATC cleared the flight for the approach and the crew accepted that clearance. If the crew instead requested the RNAV approach, then what differences might we expect in the outcome? The RNAV (GPS) RWY 18 has the same minmums, same VGSI inop note, same approach path fixes and same altitude restrictions.

A Squared

3rd Mar 2014, 15:41

aterpster:
Your ridiculous post also shows that you are clueless when it comes to Part 121 Operations.

Bwaahahhahaha, yeah, he probably didn't pick up anything about 121 Ops in his 26 years at TWA.

Somebody here is clueless, that's for sure.

aterpster

3rd Mar 2014, 15:41

wood:

Your recollections are not correct and you lose all credibility when you make untrue statements. Your ridiculous post also shows that you are clueless when it comes to Part 121 Operations.

Please review the docket and come back to us when you have something constructive to say.

Instead of being a jerk why not be specific for the sake of the forum if not me?

Are you (or were you) a Part 121 pilot?

aterpster

3rd Mar 2014, 15:47

The dispatcher also told NTSB Staff that he reviewed the localizer approach to runway 18 at KBHM prior to dispatching UPS1354 using the Jeppesen E-link to view the approach chart, and determined that the localizer approach to runway 1849 was not legal due to the note in the minimums section of the chart stating the approach was not authorized at night. The dispatcher further told NTSB Staff the RNAV approach was available to the crew, and that was the legal basis for him dispatching the flight to BHM, and there was nothing in the paperwork advising the crew that there was only one approach available to them.

14 CFR 121.601 “Aircraft dispatcher information to pilot in command: Domestic and flag operations” states, in part:

(a)The aircraft dispatcher shall provide the pilot in command all available current reports or information on airport conditions and irregularities of navigation facilities that may affect the safety of the flight.

The dispatcher of UPS1354 told NTSB Staff he did not speak with the crew of UPS1354. He did not advise the captain of UPS1354 the status of the localizer approach, telling NTSB Staff he did not know if he would tell the crew that approach was not authorized at night because “professional to professional they would probably be insulted for me saying that.” He assumed the crew knew about the chart since they used the charts every day. The dispatcher also told NTSB Staff that he generally did not talk to the pilots, and usually the reasons he would talk to them was during the initial boarding after the crew discovered an MEL not on the flight plan, something new on the airplane, or they would talk about significant weather enroute or at the destination.

The UPS Flight Control Shift Manager told NTSB Staff if there was one approach to that runway that the dispatcher was informed was illegal for the runway, the dispatcher would “absolutely” be required to inform the crew.

Desert185

3rd Mar 2014, 16:05

Aterpster:

I have, for a long time, been skeptical of dispatch and some of their decision making. They fly a stationary desk, while mine is moving at 600MPH. While they should point out certain things, it is the PIC's responsibility (as you know) to review all information related to the flight. Self-reliance, in my experience, has always been a major factor in self-preservation for me.

UPS (when I was there) was quite thorough in disseminating everything needed for the flight, particularly NOTAMS of every variety. However, things did fall through the cracks, causing me to occasionally question certain things. I may not always be the sharpest knife in the drawer at zero dark thirty, but I do pay attention to the details. I put more weight on the pilots for the safety aspects of the preflight, flight and postflight than the dispatcher's capability, regardless of his or her being an important resource/dually responsible for the safe conduct of the flight.

Why did the controller suggest the LOC RWY 18? Why did the crew not request the RNAV? Why did the crew make so many compounding errors during the approach? Why was the F/O along for the ride and not thinking like a PIC/PNF/PM? When I was there, we were supposed to be stable by 1,000' IFR and 500' VFR (which might have changed to 1,000' before I left). Why didn't they go around? Other than the occasional jumpseat, I'm not familiar with the workings of the A300-600. Why did they only partially use the automation available (since automation dependency seems to be the current preferred policy)? Fatigue? They had enough years flying those flights to be able to mitigate any fatigue enough to safely conduct the flight. Being an international guy, I could do a +/- nine hour duty day with a couple of short legs standing on my head. There are folks in line begging to go to work for UPS and fly similar schedules, which have been flown time and time again with successful results. Is this really a failure of the current system in general? Too many questions that will forever be unanswered I'm afraid.

FWIW, the airplane I was on (steam gauge, Classic 747) would have required a non-precision approach to be hand flown. As a result, I think the pilot flying is more involved and in the loop, and would most likely fly the approach with more accuracy than the way it was attempted with 1354. They were just barely hanging on to the tailskid during that event. Sad state. RIP

akwood00

3rd Mar 2014, 16:28

aterpster:

What specific information did the dispatcher not provide the flight crew?

If the FAA wants a dispatcher to speak to the captain prior to every flight that would be just fine, or if not every flight, they should define a minimum threshold for when that briefing should be required to take place. I'll tell you right now that there is no way they can have 25 briefings per night and still be able to do all of the required tasks.
How many flights does a Domestic dispatcher working a midnight shift at TWA work? What about other 121 airlines?

The Flight Control Shift Supervisor stated that typically the domestic desk would work about 25 flights. Midnight to 6am shifts could see about 22 to 25 flights. UPS tried to have dispatchers cover no more than 28 flights on the domestic side that would require to be planned. They did not consider the complexity of the operations for domestic. They did consider the complexity for international flights. Dispatchers would rarely work over 25 flights, and the maximum was 28 flights.

I am not and I never have been a Part 121 pilot, I am much more conversant with regulations that apply to dispatchers than I am those that apply to pilots.

aterpster

3rd Mar 2014, 16:45

wood:

How many flights does a Domestic dispatcher working a midnight shift at TWA work? What about other 121 airlines?

The bulk of TWA's flight were dispatched during the day. Not so with UPS. Staffing should be adequate for the task. When there is something wrong with an approach chart the dispatcher has a greater duty, morally if not legally.

The first 8 years, or so, I was with TWA we had three dispatch offices: LAX, MKC, and JFK (may have been one in Paris, too). I was based at LAX most of my career except 2 years at MKC while a dispatch department was still there.

Most pilots made an effort to speak directly with the dispatcher during those 8 years. After 8 years all dispatch was moved to JFK. I spoke by telephone with dispatchers after the consolidation, but I always made the telephone call.

Our senior VP of Flight Ops wanted to get rid of dispatch just before he moved them all to JFK. His view was that the captains essentially self-dispatched in any case. He was not able to get his idea past the FAA.

BARKINGMAD

3rd Mar 2014, 17:04

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

As OBD has already pointed out, the words "SINK RATE" loudly annunciated by PM whilst reaching for the control column and thrust levers, would be more appropriate in this rapidly deteriorating flight path.

Please don't post verbose rubbish like this, it's just as bad as "one thousand feet to level off", too many words and too much obstruction of other audio cues! :(

akwood00

3rd Mar 2014, 17:13

aterpster:

"When there is something wrong with an approach chart the dispatcher has a greater duty, morally if not legally."

We know now that there was a NOTAM issued that removed the night time restriction for the LOC 18 approach. JEPPESEN missed it and failed to remove it from the plate and it was not in the flight planning system because it was canceled. So how would the dispatcher have known about this irrelevant discrepancy?

Please answer the question as to what the dispatcher did not provide the flight crew. Please tell us you have something more than old TWA stories to back up your accusations?

aterpster

3rd Mar 2014, 20:55

wood:

Please answer the question as to what the dispatcher did not provide the flight crew. Please tell us you have something more than old TWA stories to back up your accusations?

Your form of confrontation is counter-productive.

Let's wait for the final report and read what the NTSB analysis and conclusions have to say about dispatch in general, dispatch that night, and the failure of the dispatch department to detect for a long time a Jeppesen chart that was defective on its face. And, why didn't they pick up on the FDC P-NOTAM when it was in the system? Other Part 121 carriers that have KBHM as a regular airport may have (probably did) made the same error of omission. But, it didn't end up biting them.

The fact that no Part 121 carrier that had KBHM as a regular airport for the period the chart was defective reported it to Jeppesen is quite telling about Part 121 dispatch departments in general.

flyingchanges

3rd Mar 2014, 22:22

Lots of 121 carriers get tailored pages. I would look at the night NA and assume that was specific to our ops, not necessarily a JEP error. I looked at our page at the time of the accident, it was tailored for our ops (not UPS), and it looked just like the plate on page 37 of the debrief.

http://dms.ntsb.gov/public%2F55000-55499%2F55307%2F550789.pdf

aterpster

3rd Mar 2014, 22:45

flyingchanges:

Lots of 121 carriers get tailored pages. I would look at the night NA and assume that was specific to our ops, not necessarily a JEP error. I looked at our page at the time of the accident, it was tailored for our ops (not UPS), and it looked just like the plate on page 37 of the debrief.

I don't know about today but when I did Part 121 our few tailored Jepps said "Tailored" in white letters on a black background.

If this had been a UPS tailored chart, which it wasn't, whoever at UPS that is responsible for tailored charts would have an even higher duty to make certain the tailored chart is what they ordered. That wouldn't be a crew members responsibility. Having said that, if a crew member sensed an issue with a Jepp chart, he or she should communicate the concerns to the company. We had a debrief form for issues like that. The local chief pilot couldn't send a debrief report to the circular file.

tubby linton

3rd Mar 2014, 22:56

Our tailored charts from Jepp have the airline name on them. Do US operators classify airfields by their difficulty and if so who is responsible for this analysis?
My employer uses a classification A-C with C being the most challenging. Airfield in class B and C have a written brief which is to be read by the crew before departure. The briefs are written by a company management pilot.

aterpster

3rd Mar 2014, 23:15

tubby:

Our tailored charts from Jepp have the airline name on them. Do US operators classify airfields by their difficulty and if so who is responsible for this analysis?

That jogs my memory. Our tailored charts had our airline three-letter code on them. As far as the FAA is concerned there is their list of special qualification airports, but nothing else.

My employer uses a classification A-C with C being the most challenging. Airfield in class B and C have a written brief which is to be read by the crew before departure. The briefs are written by a company management pilot.

If your company does this on their own initiative, more power to them.

GlobalNav

3rd Mar 2014, 23:24

The Operations Group Factual Report, Chapter 11 addresses the issue of the Jeppesen Chart. The extract below fairly well covers it:

"The Jeppesen 11-2 KBHM LOC18 chart used by the crew of UPS1354 indicated that NOTAM 1/3755 (amendment 2A) was incorporated, however the minimums section of the chart was not changed to reflect the NOTAM. Following the accident, Jeppesen reissued the 11-2 KBHM LOC18 chart on September 13, 2013 that removed the night NA restriction in the minimums section of the chart."

I wonder if the question regarding the chart and the dispatcher are truly a contributing factor in our search for ways to prevent such accidents. Indeed, the LOC 18 was legal for night operations with an operable VGSI - which it was. Had the crew decided or been advised by the dispatcher to fly the RNAV (GPS) Runway 18 procedure instead, they would have had the same approach path, VGSI note, FAF and approach fixes, same altitude restrictions, minima, visiblity and so forth.

So isn't the point moot, accident-wise, unless we want to just point fingers?

DMJ618

4th Mar 2014, 00:58

It appears the closing of runway 6/24 took them by surprise. In the transcript the first time they knew about this was after receiving ATIS information and then they did the briefing. Wouldn't that mean that they didn't even bother to read the paperwork from dispatch anyway? Is it normal to just scan the paperwork from dispatch preflight?

A Squared

4th Mar 2014, 01:11

So isn't the point moot, accident-wise, unless we want to just point fingers?

Thats kind of my take on it. It's a bit like the discussion on the incorrect "Procedure N/A at night" note in the original thread. A lot of ink was spilled about the fact that they (the crew) didn't see the note, but at the end of the day, the procedure was in fact "A" at night, so they were flying an authorized procedure, and the incorrect note was not a factor in the accident.

aterpster

4th Mar 2014, 01:25

GlobalNav:

Had the crew decided or been advised by the dispatcher to fly the RNAV (GPS) Runway 18 procedure instead, they would have had the same approach path, VGSI note, FAF and approach fixes, same altitude restrictions, minima, visiblity and so forth.

Except they would have had a Baro VNAV path as part of the database approach; e.g., a perhaps much easier task for them than trying to meld FMS paths with a LOC procedure.

Anything dispatch did, or failed to do, is minor compared to this crew's (presumed with the RNAV 18) lack of judgment and competency for either IAP to Runway 18. Nonetheless, dispatch is "fair game" in the overall scheme of a Part 121 accident investigation.

A big part of such investigations is supposed to be to avoid a repeat.

DMJ618

4th Mar 2014, 01:53

Would any pilots here actually have been offended by a dispatcher giving you a heads up about the closed runway and the fact that a non-precision approach on a short runway is what you have instead?

767__FO

4th Mar 2014, 04:10

"Would any pilots here actually have been offended by a dispatcher giving you a heads up about the closed runway and the fact that a non-precision approach on a short runway is what you have instead?"

I would say thank you.

Showbo

4th Mar 2014, 05:02

aterpster:

Except they would have had a Baro VNAV path as part of the database approach; e.g., a perhaps much easier task for them than trying to meld FMS paths with a LOC procedure.

Nope.... GlobalNav is correct. With the exception that the crew would have selected NAV instead of LOC for the roll mode (and an interim step-down fix prior to BASKN), the two procedures would be flown the same way. The nuts and bolts for Final Approach Mode are the same for both IAPs.

The irony of it is that if they had chosen to do the RNAV (GPS) 18, the controller would have cleared them to a fix, or to intercept the the final course. This would have almost certainly prompted them to extend the center line (sequence the FMC) or they would have failed to capture the inbound course.... a very big clue, hard to miss. This then would have been the missing step that would activate the vertical profile, and no reason why it shouldn't have captured. Then we wouldn't be having this conversation.

DMJ618

4th Mar 2014, 05:45

The dispatcher expected them to use the RNAV approach; he had the chart without the night LOC correction, so he did think it was N/A. He also gave them an alternate (Atlanta, I think?) since they only had one runway with one approach.

It would have made more sense to me to have simply delayed the trip by a half hour, and give BHM time to finish the work on 6/24. Or... to give the crew the heads up about the situation.

aterpster

4th Mar 2014, 13:56

Showbo:

Nope.... GlobalNav is correct. With the exception that the crew would have selected NAV instead of LOC for the roll mode (and an interim step-down fix prior to BASKN), the two procedures would be flown the same way. The nuts and bolts for Final Approach Mode are the same for both IAPs.

My "low end" Garmin WAAS navigator provides "LNAV+V" on the RNAV 18. So, in this case it is flown like a precision approach, albeit with NPA obstacle clearance. If an LNAV IAP has a VDA on source, Jeppesen codes the vertical path. I would think in general terms most modern air carrier FMS systems would provide a Baro VNAV path when the source includes a VDA and Jeppesen codes it.

If not, then a guy with a Garmin WAAS navigator is better off on Runway 18 that the big package delivering bird.

I flew the 767, but it was so long ago that VNAV was not even authorized.

EDIT TO ADD: I checked with group I work with who are both avionics designers and biz jet pilots.

They told me that the Collins, Universal, and Honeywell FMSes would provide an "advisory" Baro VNAV path in the BHM RNAV 18 final approach segment.

akwood00

4th Mar 2014, 14:45

aterpster stated:

"Your form of confrontation is counter-productive.
Let's wait for the final report and read what the NTSB analysis and conclusions have to say about dispatch in general, dispatch that night, and the failure of the dispatch department to detect for a long time a Jeppesen chart that was defective on its face. And, why didn't they pick up on the FDC P-NOTAM when it was in the system?"

You're pretty hung up on the "failure" of dispatch to detect the NOTAM removing the night restriction. I would bet that more than 90% of the time most airlines utilize runways 6-24 in BHM. So why would a pilot or dispatcher even analyze the other runways NOTAMS (if they actually had the NOTAMS) and compare them to the charts. A professional airman has a reasonable expectation that Jeppesen has kept up with the plates and to help you finally put this to bed, I'll point out that the FAA already has.
Please see the docket titled Operations 2 Exhibit 2-FF - Attachment 31 – FAA Responses

aterpster

4th Mar 2014, 15:44

wood:

You're pretty hung up on the "failure" of dispatch to detect the NOTAM removing the night restriction. I would bet that more than 90% of the time most airlines utilize runways 6-24 in BHM. So why would a pilot or dispatcher even analyze the other runways NOTAMS (if they actually had the NOTAMS) and compare them to the charts. A professional airman has a reasonable expectation that Jeppesen has kept up with the plates and to help you finally put this to bed, I'll point out that the FAA already has.
Please see the docket titled Operations 2 Exhibit 2-FF - Attachment 31 – FAA Responses.

The FAA hasn't put anything to rest. All they are saying is the approach was legal in spite of the erroneous Jepp chart because the subject FDC NOTAM worked in their favor. The FAA also states such a NOTAM could work against the operator when a NOTAM is restrictive rather than permissive.

Air carriers, unlike non-commercial operators, are responsible for the accuracy of either Jeppesen or LIDO charts. If you are familiar with the requirements of air carrier operations specifications you should know that the FAA does not approve either Jeppesen or LIDO charts. They merely "accept" them as submitted by the carrier into its operations specifications. The carrier is jointly responsible with Jeppesen for the charts to accurately portray the FAA-issued standard instrument approach procedure.

Nothing in the attachment you make reference to suggests that the FAA is not still looking at the UPS dispatch department (or charts department if UPS has one).

Desert185

4th Mar 2014, 16:32

OK465

If you need to make time and fuel burn is a lesser concern than getting there closer to on time, FL270 (the highest TAS flight level in a 747) will net you ~530KTAS, which breaks 600MPH.

Sorry for the thread drift...

Showbo

4th Mar 2014, 17:37

aterpster:

Honeywell FMSes would provide an "advisory" Baro VNAV path in the BHM RNAV 18 final approach segment.

Yes, it does, and it does EXACTLY the same for a BHM LOC 18 flown in Profile Mode (Airbus speak for VNAV). Forgive me if I'm wrong but I'm getting the impression that you think that the vertical path information they had would be better if they'd elected the RNAV GPS approach. If so, you're barking up the wrong tree. The vertical nav path info is the same in both cases. And yes, the A300 would fly it just like an ILS.

The captain elected and briefed a Localizer approach to be flown in Profile and they set it up that way. But the Airbus switchery is a little cumbersome and doesn't lend itself to situations in which you are rushed (e.g. you were a bit slow on the uptake or ATC keeps you high and close). The NTSB docket info shows that the crew selected gear down at around 9000 feet in a 250 kt descent to 2500ft then continued to decelerate and configure all the way to BASKN and made several scoffing comments about being kept high while on the way there. Rushed? The NTSB hearing examination of Panel 1 highlighted the need for several very distinct steps needed to activate the profile or it just plain won't work. The crew omitted sequencing the FMC so never had a profile to follow, but probably didn't realize it. The crew never mentioned that they could have descended to 2300ft once they captured the localizer so when they crossed BASKN at 2500ft, the captain once again scoffed about being "kept high" by which time he had selected Vertical Speed. I won't speculate about what his intentions were.

But if the same mistakes were to be made, the RNAV approach would not have made any difference with one exception..... if they had been cleared direct to COLIG and correctly used the FMC to navigate to it, then the FMC would have correctly sequenced and the vertical profile would have come alive.

aterpster

4th Mar 2014, 17:42

Show:

Yes, it does, and it does EXACTLY the same for a BHM LOC 18 flown in Profile Mode (Airbus speak for VNAV). Forgive me if I'm wrong but I'm getting the impression that you think that the vertical path information they had would be better if they'd elected the RNAV GPS approach. If so, you're barking up the wrong tree. The vertical nav path info is the same in both cases. And yes, the A300 would fly it just like an ILS.

Thanks. Makes more sense to me now.

DMJ618

4th Mar 2014, 17:52

Since I really believe this took them by surprise, I'm also left wondering if they didn't know that the runway would be open so soon. Would they have asked to be put in a holding pattern for the few minutes it took to finish the work and clear the vehicles off the runway? If only ATC had let them know this was an option. I mean, sure maybe by that point they were so tired they just wanted to get on the ground and to the hotel; but they also might have been so tired and realized that the workload and concentration necessary increases substantially when they have...
- an unfamiliar runway and terrain
- nonprecision approach
- short runway
- at night
- low level patchy clouds (they may not even see the runway)
- etc...anything I might have missed
that they would rather wait for the ILS approach.

Showbo

4th Mar 2014, 23:32

DMJ618:

Sorry, DMJ, you're not getting many takers!

Your comments are all valid, and yes, I wouldn't have been offended by a "heads up" on the LOC18.

One of the risks you list....."- low level patchy clouds (they may not even see the runway)".... appeared to be an item of particular interest in the NTSB's hearing.

The ATIS they got told them, "Visibility one zero. Sky condition, ceiling one thousand broken. Seven thousand five hundred overcast."

From the Operational Factors Report, page 31 ....
http://dms.ntsb.gov/public%2F55000%2D55499%2F55307%2F550741%2Epdf

The remarks section of the 0353 CDT (0853Z) weather observation that included the automated observation of a 600 foot ceiling variable to 1,300 foot ceiling was not included in the ATIS received by UPS1354.

The pages around that quote (29 onwards) are about why those remarks were missing. I guess the NTSB are wondering if the crew might have been a bit more circumspect about what they were about to do if they had received those remarks.

GlobalNav

4th Mar 2014, 23:54

Sorry, no disrespect intended, but "circumspect" is not the first thing that comes to mind with this crew. They HAD the required visibility needed to commence the approach. They knew that the MDA was 1'200 ft and I believe they knew what it meant. We know that instrument approach procedures include a key pilot decision no later than minimums that the requirements of 91.175(c) are met for continued descent and operation. Sufficient for safety with or without the remarks. They just didn't seem to know they passed through minimums, apparently ill aware of their vertical position. In my opinion, ill served by the VS mode.

That said, I think the investigation uncovered a shortcoming in the LIDO system, which oddly is shared with the ACARS (same source perhaps) and the ATIS. No excuse for the latter in my opinion. Not a significant contributor, but should be fixed anyway.

glendalegoon

5th Mar 2014, 00:02

think about pre flight considerations.

read notams that runway is closed until X

read wx and note that an approach will be required

think. if I slow to slow economy cruise and get there a few minutes later I can do a simple ILS rather than a non precision approach to a shorter runway with odd rolling hills in front of it at night. and I might save a gallon or two of fuel

hmmm

Showbo

5th Mar 2014, 00:20

GlobalNav....
Non taken. I'm just trying to be circumspect about my comments ;)

aterpster

5th Mar 2014, 00:54

glendalegoon:

think about pre flight considerations.

read notams that runway is closed until X

read wx and note that an approach will be required

think. if I slow to slow economy cruise and get there a few minutes later I can do a simple ILS rather than a non precision approach to a shorter runway with odd rolling hills in front of it at night. and I might save a gallon or two of fuel

All very good points. But, the operative words you cite are "think" and "read."

bubbers44

5th Mar 2014, 02:31

DMJ618

5th Mar 2014, 13:40

Most of us have never been concerned about what approach we got so just wanted to be headed for the hotel. We knew we could do all of the approaches never even considering we could end up crashing. I think they were not making any bad decisions by what they tried to set up for their approach but they made a big mistake that they didn't think they could ever do.

I don't know, if we were talking 5pm instead of 5am, maybe. Fanning did express concern about the runway, she said something about being heavy. I think they took on more cargo than whatever is normal for them. For that reason, I don't think it would have been too difficult to convince her to wait for the longer runway.

Also, reading the NTSB reports or watching the hearing, they do state that UPS pilots don't do nonprecision approaches very often. My impression was that they did them in sim training, and that was about it. For that reason, I would assume they would very strongly prefer an ILS approach. But who knows, they may have had more confidence in themselves and the plane?

I have to admit, if they were at all nervous about this approach, why didn't they go around when they heard the tower and ground workers saying that the work was done and 6/24 will open soon?

glendalegoon

5th Mar 2014, 13:46

two words: visual deception

aterpster

5th Mar 2014, 14:00

DMJ618:

I have to admit, if they were at all nervous about this approach, why didn't they go around when they heard the tower and ground workers saying that the work was done and 6/24 will open soon?

Why did they bust minimums and descend at 1,500 FPM?

Seems to me they had no concept of the hazards unique to a NPA and they just wanted to get on the ground.

DMJ618

5th Mar 2014, 14:20

DMJ618:

Sorry, DMJ, you're not getting many takers!

Your comments are all valid, and yes, I wouldn't have been offended by a "heads up" on the LOC18.

One of the risks you list....."- low level patchy clouds (they may not even see the runway)".... appeared to be an item of particular interest in the NTSB's hearing.

The ATIS they got told them, "Visibility one zero. Sky condition, ceiling one thousand broken. Seven thousand five hundred overcast."

Thank you, Showbo. I'm not surprised. I'm a newbie and obviously not a pilot. This crash has captured my imagination and I've read everything I can find, including looking up anything I don't understand. And honestly, the discussion on this forum has been the most informative (I've read the other thread too). If I'm intruding or a nuisance I expect someone will say, hey lady get over to spotters or passengers where you belong! lol and I'll go back to lurking.

One question, if you only had the ATIS that they did, wouldn't 1000 ft clouds be a possible concern when your decision height is 1250? Even if they had the glide path, they need to be visual at 1250, (or was it 1380?) correct?

DMJ618

5th Mar 2014, 14:29

Why did they bust minimums and descend at 1,500 FPM?

Seems to me they had no concept of the hazards unique to a NPA and they just wanted to get on the ground.

There is that. I don't think they had any concept of the hazards unique to 18 either. They thought they were home free when they had the runway in sight, so they couldn't have possibly have known about the hill.

A Squared

5th Mar 2014, 14:41

One question, if you only had the ATIS that they did, wouldn't 1000 ft clouds be a possible concern when your decision height is 1250? Even if they had the glide path, they need to be visual at 1250, (or was it 1380?) correct?

the cloud height on the ATIS is in feet above ground level (AGL) the Minimum Descent Altitude is in feet above Mean Sea Level (MSL)

the airport is at 650 MSL so the 1000 ft cloud layer would be at 1650 MSL, above the MDA

DMJ618

5th Mar 2014, 14:51

Thank you, A Squared. I thought they were both MSL.

GlobalNav

5th Mar 2014, 14:55

@ A Squared. I agree.

However, you might find the Aircraft Performance Group Report's treatment of this to be interesting. The analyst viewed numerous videos from the airport, noting both position, intensity of the aircraft's landing lights, time and so forth. The apparent conclusion being that there was cloud obscuration of the landing lights anyway as the airplane was passing approximately 1,000 ft MSL. Can't really conclude what the crew would have seen and when, if they were looking. No indication in the CVR transcript that they were looking until after the Sink Rate alert. All of this, of course, way below the 1,200 ft MDA.

DMJ618

5th Mar 2014, 15:48

GlobalNav, you have cleared up some confusion for me. Thanks! But... now I have more questions.

They may have been aware of the terrain and had no concern since they expected to descend through the clouds at around 1000 AGL/1650 MSL, as I understand now? The fact that they didn't may have contributed to their lack of vertical awareness?

Showbo

5th Mar 2014, 17:09

DMJ:

They may have been aware of the terrain

Actually, they may not have been particularly aware of the terrain. The thing about BHM is that it's hilly, not mountainous. I can't remember if the NTSB has established whether either of them had landed on 18 before, but I'm pretty sure that at least the captain had landed on the longer runway a fair few times. The hills for 06/24 are further away from the respective runway thresholds. The thing about 18 is that those small hills come all the way up to the threshold making the tolerances so much tighter in the last couple of miles. That's one of the issues aterpster is so hot about. There is little margin for error. If you look at the charts (pre-crash) the crew had....http://dms.ntsb.gov/public%2F55000%2D55499%2F55307%2F549718%2Epdf
...... there's little there that might point this out. You could look at similar charts for an airport near mountainous terrain and there would be all sorts of colored contours and warnings plastered all over them.

had no concern since they expected to descend through the clouds at around 1000 AGL/1650 MSL

Probably. You can Google "expectation bias" to do with aviation.

GlobalNav

5th Mar 2014, 17:28

DMJ. I am probably too tempted to speculate so I won't. Remember it was night time, IMC, though visibility reported to be ten miles. I wouldn't expect to see much terrain even though it's there, because of the darkness.

Wouldn't the altimeter be the primary cue for altitude, reaching minimums, and deciding to continue or go-around based on the required visual references? Can we suspect the crew was relying totally on the reported cloud height rather than their own instruments and real time view out the window?

As I have said before, perhaps the pace of the approach affected their anticipation of the event milestones. Twice the normal vertical rate, MDA twice as high above touchdown than they usually experience, means they reach MDA before their minds tell them to expect it. I may be wrong. But something must account for the mental picture they held.

I am not meaning to disparage the crew. What can be done to reduce the vulnerability of other crews to the same factors?

DMJ618

5th Mar 2014, 18:51

I didn't think they would rely entirely on the cloud ceiling, but it may have been one more thing that led them to believe they were higher than they were.

From the beginning, I simply couldn't understand how x could happen, or why they chose to do y instead of z. My "x, y, and z" are things that the pilots here already know. All I had was speculation, and very uninformed and ignorant speculation at that. And so, I really appreciate the depth of knowledge and expertise here. I'll sit back and wait for the NTSB report or any further news and look forward to reading the opinions here.

Desert185

5th Mar 2014, 19:07

Global

I am not meaning to disparage the crew. What can be done to reduce the vulnerability of other crews to the same factors?

Any discussion of the facts in this accident leads to disparagement of the crew, at least in my opinion. Plain and simple.

This was my airline for just short of 20 years, and I was a check airman for the majority of that time (DC-8 & B-747), and as a result I somewhat take it personally when my airline has an accident like this. The training on the two fleets I helped crew was conducted by very experienced, prior airline people with experience on type. As the airline grew, that changed. People were hired into fleet management off the street, in many cases, without previous airline experience or time in type. Crewmembers, filtered by HR hiring goals, were hired who were not necessarily the best technical candidates for the basic requirement of being an instrument pilot. Some were not even considered for interview, even though they had substantial time in type (but minimal or no college) along with a sterling work record, and others were interviewed because they met certain HR profiles and had four years of college but with minimal flight experience.

So you tell me, what can be done to reduce the vulnerability of other crews to the same factors? I think it is fairly obvious when success generally begins with a proper grasp of the basics based on the knowledge and experience of those who have gone before you...and applied to the best candidates available. Simple, but not so simple when exposed to the pressures of political, PC influences.

At least that's how I see it, but then I'm getting old and probably don't know what I am talking about. :ugh:

40&80

5th Mar 2014, 19:25

Sir, You know exactly what you are talking about....the pity is nobody in the HR department has the background cockpit experience to understand this or if they do they are incapable of action.

tubby linton

5th Mar 2014, 19:43

If I was the boss of the airline I would be looking at my route structure and looking for the airfields that did not provide an ILS onto a 8000ft long runway that was free of terrain and obstacles and grading the airfields that did not fit this criteria by difficulty.
I would have a department of experienced pilots looking at the risks my line pilots were exposed to and developing training programmes to make sure my line pilots could deal with the risks that had been discovered. I would also be equipping my fleet with TAWS including terrain depiction on the efis map display and a 21st century FMS that was easy to use and capable of flying all approaches easily.
I would also be asking the chart manufacturers to provide distance/altitude tables on non-precision approaches and also depicting minimum safe altitudes for each segment of the approach for every airfield used.

GlobalNav

5th Mar 2014, 19:50

@Tubby. I share your sentiments. As a previous poster, Tom Imrich in Post #92 noted, it's time to make use of available technology and put precision approaches at these runways. GLS is here, it needs to be exploited. A single GBAS at an airport can enable precision approaches for practically every runway at the airport, perhaps even nearby airports for the price of a new approach procedure. Then every approach will work and look like practically every other one and the training problems and error prone procedures can be replaced. This is what NextGen should be about.

akwood00

5th Mar 2014, 21:43

"The thing about 18 is that those small hills come all the way up to the threshold making the tolerances so much tighter in the last couple of miles."

I'm sure there are lights on those hills, just like there are lights on towers and cranes. I wonder if any lights were NOTAM'd inop. A bright red beacon placed atop of an obstacle located in the approach path to a runway seems like a good idea, especially for pilots flying in there at night.

GlobalNav

5th Mar 2014, 22:03

Granted the terrain profile is interesting. But the terrain didn't grab this airplane, it just interrupted an extremely and inappropriately steep flight path. The procedure, flown properly, met all the obstacle clearance requirements, albeit perhaps a bit less forgiving.

Had the terrain been flat, the sink rate alert would have been delayed, the 1,500 FPM VS would have continued, unabated, whilst the AP remained coupled. The paltry response to the sink rate alert may have been just as inadequate over flat terrain as it was at BHM. Perhaps a careful technical analysis would disprove that assertion, but the cause of this accident was, nevertheless, a badly flown approach.

Will additional training correct the situation? It might help, but, the operator already thought it was doing enough and given the high costs of training, how much more would they be prepared to do? It will not change the relative infrequency of nonprecision approaches, and crews' relative inexperience with them.

Time is marching on. It's time to improve the safety of operations. We may have fewer nonprecision accidents than we used to, but I suspect it's because fewer are flown. Not a bad thing, except crews are even less familiar with all the intricate FMS steps to fly them. We should get nonprecision approaches out of the menu as soon as possible and replace them with GLS precision approaches.

aterpster

6th Mar 2014, 13:40

Wood:

I'm sure there are lights on those hills, just like there are lights on towers and cranes.

I doubt there were any obstruction lights. It is a grassy field that was subjected to earth moving after the houses were removed, probably a long time ago. Nothing about that terrain meets obstruction lighting standards.

The PAPI was mandatory at night, at least for the two IAPs, which is all the obstruction lighting that was required for the Runway 18 close-in approach path.

aterpster

6th Mar 2014, 13:53

GlobalNav:

Time is marching on. It's time to improve the safety of operations. We may have fewer nonprecision accidents than we used to, but I suspect it's because fewer are flown. Not a bad thing, except crews are even less familiar with all the intricate FMS steps to fly them. We should get nonprecision approaches out of the menu as soon as possible and replace them with GLS precision approaches.

FAA close-in obstacle clearance standards simply will not permit an approach with vertical guidance (FAA-speak these days for ILS, LPV, GLS, and LNAV/VNAV).

First, there is a TERPs criterion called the GQS (glide-slope qualification surface) which must be met from the DA point to the runway. Second, there is the wider visual segment, which ideally should be 34:1 on the sides of the GQS. The visual segment can have 34:1 penetrations, which can affect minimums. But, if a 20:1 is violated the FAA is "on a roll" to deny night minimums altogether unless there is a flight inspected VGSI (such as at BHM 18) that serves to mitigate the hazards at night in the visual segment. The Runway 18 PAPI (one type of VGSI) was not approved for some period of time. Then, it was flight inspected at the NOTAM at issue was issued to permit night minimums provided the VGSI was operating.

There are a lot of runway ends in the U.S. that have been disapproved for night IFR landing. This all came about when a Lear Jet hit some trees on short final that penetrated the 20:1 in the visual segment of an IAP.

There are an increasing number of GA runways that cannot meet the GQS requirements, so instead of having LPV, they have LP.

GlobalNav

6th Mar 2014, 14:55

@aterpster. Thank you, I grant that there can be a host of details, maybe even impossibilities that prevent establishing precision approaches at every runway. In addition to the obstacle criteria you mention there are also infrastructure requirements for runway and approach lighting to account for.

In my judgement it was not the night nor the terrain/obstacles that created this accident, but your points are well taken.

This is perhaps "out of the box", but I would be happy if the minimums remained the same, for the sake of the terps, but rather than this pseudo vertical flight path nonsense there be an established vertical path a la ILS or GLS that from the flight deck perspective is as straight-forward to set up and fly as today's ILS approaches.

It is a multifaceted problem requiring a multifaceted solution, that certainly includes training and so forth. I do believe its time to address Rube Goldberg nonprecision approaches, no matter how well meaning. I am not satisfied to stop at the notion of "pilot error" without finding truly effective means to prevent it. This crew had a bad night, but I doubt they are all that unique amongst their peers in the business. Things are not entirely like they were 30 years ago and we need to stop trying to shoehorn today's reality into our assumptions from the good old days.

Ian W

6th Mar 2014, 17:03

GlobalNav:

FAA close-in obstacle clearance standards simply will not permit an approach with vertical guidance (FAA-speak these days for ILS, LPV, GLS, and LNAV/VNAV).

First, there is a TERPs criterion called the GQS (glide-slope qualification surface) which must be met from the DA point to the runway. Second, there is the wider visual segment, which ideally should be 34:1 on the sides of the GQS. The visual segment can have 34:1 penetrations, which can affect minimums. But, if a 20:1 is violated the FAA is "on a roll" to deny night minimums altogether unless there is a flight inspected VGSI (such as at BHM 18) that serves to mitigate the hazards at night in the visual segment. The Runway 18 PAPI (one type of VGSI) was not approved for some period of time. Then, it was flight inspected at the NOTAM at issue was issued to permit night minimums provided the VGSI was operating.

There are a lot of runway ends in the U.S. that have been disapproved for night IFR landing. This all came about when a Lear Jet hit some trees on short final that penetrated the 20:1 in the visual segment of an IAP.

There are an increasing number of GA runways that cannot meet the GQS requirements, so instead of having LPV, they have LP.

I believe one of the problems with the current approach to RNP and GLS is that instead of looking at the new capabilities that they provide for varied glide paths and curved approaches, the tendency instead is to create procedures for GLS to emulate ILS approaches. For this reason the air carriers see no reason to equip and train for RNP/RNAV/GLS as they can get the same approach using ILS. Sometimes better as with closely spaced parallels the controller regulations still require the aircraft to be 'established on the localizer' :ugh: so no RNP approaches.

More needs to be done to take full advantage of the capabilities of GLS the ground installation is cheap and simple and GBAS does not require repeated calibration. The pilot training is not exceptional either and if it was the standard instrument approach then all the flying schools would teach it.

But the major unexploited advantage is that you can be fully 'established' 'stabilized' on a GLS procedure with turns and changes of vertical profile as part of the automated final approach. Yes it will make it different for the procedure designers used to using straight lines at fixed descent rates for final approach and the definition of obstacle clearance surfaces may have to change, but the prize is standard instrument approaches to all runway ends anywhere.

aterpster

6th Mar 2014, 17:40

IAN W:

But the major unexploited advantage is that you can be fully 'established' 'stabilized' on a GLS procedure with turns and changes of vertical profile as part of the automated final approach. Yes it will make it different for the procedure designers used to using straight lines at fixed descent rates for final approach and the definition of obstacle clearance surfaces may have to change, but the prize is standard instrument approaches to all runway ends anywhere.

RNP AR already offers a stabilized approach with RF legs as necessary, and a short, straight final segment (just prior to DA if necessary). But, both the FAA and ICAO are hard-over on the benign obstacle clearance environment in the visual segment. The equipment requirements are also burdensome.

RNP AR blending with GLS would be the ideal solution. But, that would require FMS redesigns and so forth.

In any case the likes of BHM Runway 18 are unlikely to benefit from future improvements in avionics. BHM 18 actually works quite nicely today with an advisory VPATH and the PAPI requirement.

A-3TWENTY

7th Mar 2014, 05:26

What was the cause of the pilot`s dead since the cockpit is relatevely intact?

I`ve heard in several accidents Airbus pilot`s seats released from the floor causing to pilots heavy injuries and dead.

ironbutt57

7th Mar 2014, 08:09

Seats remained attached..blunt-force trauma which can be either from striking an object, or a result of severe G's experienced during aircraft impact..resutling in internal injuries...

NOLAND3

7th Mar 2014, 21:35

Are you sure the seats remained attached? Pretty sure the captains seat was found outside & forward of the the cockpit. F/O seat remained attached.

Passenger 389

7th Mar 2014, 22:28

The seat was found outside the plane, but NTSB attributes that to extrication efforts:

[QUOTE]"The captain’s seat was found outside the airplane, lying next to the forward fuselage. The seat was mostly intact, and the forward seat pan area was bent downward. The floor under the seat was buckled upwards several inches and the seat pedestal base mounting structure was pitched forward, accordingly. The pedestal base was severed at the floor, consistent with reported extrication efforts ...."[QUOTE]

NTSB Survival Factors Exhibit 6-A Factual Report of Group Chairman

Document 42 ATC 3 - Attachment 1 - BAA - ATC Airport Emergency Operating Procedures Letter of Agreement Filing Date December 16, 2013 4 page(s) of Image (PDF or TIFF) 0 Photos (http://dms.ntsb.gov/pubdms/search/document.cfm?docID=410012&docketID=55307&mkey=87780)

[ Note: the URL link is correct, despite the incorrect description automatically appended to my post.]

The same document discusses the relevant autopsy findings regarding the flight crew. You can draw your own conclusions from it. Several photos in that document also offer an idea of the impact experienced.

Dimitrii

10th Mar 2014, 05:38

Airline warns pilots to avoid Birmingham runway after UPS crash (http://blog.al.com/wire/2014/03/airline_warns_pilots_about_run.html#incart_hbx#incart_best-of)

aterpster

10th Mar 2014, 13:36

Their analysis is flawed.

Coagie

11th Mar 2014, 10:19

The larger parallax created by the PAPI lights being only 47' above ground, instead of 75' above ground may have been enough to obscure them from the pilots view. I don't think he ever saw the PAPI lights. If he'd seen the PAPI lights, he'd have seen the bad indication, and it would have cued him to go around. Instead, coming down fast out of the low clouds, he saw the runway, and it gives little indication other than where to aim. If anything, it said to him "I'm here. Put it on the tarmac". Of course, that doesn't excuse not going around, when he came down so fast and steep while approaching an unfamiliar runway, but it could be what happened. I think 9999 out of 10,000 times, in the same situation, the pilot would have made the right judgment and gone around, but the one time he didn't, it ended up being the final hole in the Swiss cheese. I think maybe not one or the other pilots being fatigued matters so much, but I think, maybe they both were fatigued, contributing to the poor judgment to go through with the landing. From what I read about these pilots, they may not have been the very best on type, but they were good, enthusiastic aviators and righteous human beings.

aterpster

11th Mar 2014, 14:25

If they had flown the procedure correctly and not departed MDA unless the PAPI was indicating "on slope" we wouldn't be discussing them.

The 47 feet doesn't mean anything unless you don't come out of the clouds way below MDA and way below the PAPI "on slope."

dera

12th Mar 2014, 02:08

Any doctors on this board? That document about survival factors and the injuries described sound like the captain died immediately, but the co-pilot could possibly have been saved, had there been a chance of immediate intensive care?

Coagie

13th Mar 2014, 13:23

aterpster
"If they had flown the procedure correctly and not departed MDA unless the PAPI was indicating "on slope" we wouldn't be discussing them.
The 47 feet doesn't mean anything unless you don't come out of the clouds way below MDA and way below the PAPI "on slope.""

aterpster, You're right, but they did come out of the clouds way below MDA and way below the PAPI. I'm just pointing out that the difference between 75 feet and 47 feet could have been the next to last hole in the Swiss cheese (The final one: Not going around).

flown-it

19th Mar 2014, 00:01

If you are going to do non- precision approach why not have PM in LNAV/VNAV and thus have a decent glide slope to back you up?
Too many pilots don't understand what a great tool GPS is in approach phase.
:ugh:

AerocatS2A

19th Mar 2014, 09:07

Didn't they try to do that but :mad: it up somehow so the VNAV never captured?

Sky Slug

20th Mar 2014, 06:26

Flying late departures then connecting to a red-eye isn't for everyone Going to sleep at 0700 doesn't work for most people, including pilots. A lot of guys I worked with flying RJs wanted a FedEx or UPS job for the pay. They pay more than the majors. The get-there-itis is off the charts in the FedEx/UPS world as they want a bed ASAP. I do the occasional trans-con red-eye to my base, NYC. We are well-rested though. It isn't a lifestyle, it is a bid package.

Amadis of Gaul

16th Aug 2014, 21:41

The F/O's husband is now suing Honeywell for improperly functioning GPWS. He's suing for a relatively low $2 million.

Husband of UPS pilot sues over deadly crash | HeraldNet.com - Business (http://heraldnet.com/article/20140816/BIZ/140819337/1005/Husband-of-UPS-pilot-sues-over-deadly-crash)

Fox3WheresMyBanana

18th Aug 2014, 01:11

I note there was no discussion between the crew of target descent rates for the VSI, or likely nose angles, nor changes thereto when they were held high.
Is this normal? Even if they had held "instrument discipline", how would they have known what to look for?
I was taught to do this for all approaches, or height changes during intercepts (RAF).

p.s. I've seen #28 were this is first mentioned, but I am wondering what is standard procedure for non-precision approach briefings (esp. at night) these days.

OD100

18th Aug 2014, 01:16

2 mil? From Honeywell. If I were on the BOD, I'd have the check cut so fast it would make his head spin!

Mozella

18th Aug 2014, 05:22

Flyboyike says: F/Os aren't qualified to fly? That's a new one.

Apparently you've never been a Captain or a Flight Engineer. In both of those seats I frequently observed that F/O's can't fly worth a toot.

Funny thing though, ................... when I was in the right seat, I didn't notice it nearly as much. :cool:

SLFgeek

25th Aug 2014, 16:46

August 25, 2014 - NTSB Revokes Party Status of a Union and an Airline for Violating Agreements (http://www.ntsb.gov/news/2014/140825.html)
August 25

The National Transportation Safety Board has revoked the party status of both the Independent Pilots Association and UPS Airlines from its ongoing investigation of UPS Flight 1354, an A300-600 air cargo flight that crashed on approach to Birmingham, Ala., last August.

Machinbird

25th Aug 2014, 18:24

having some nights,with Postal services...sleep becomes to be the prime,and mixing it with else,s everyday life..morning arrivals are,-well you know. I have fallen in sleep in finals,many times,microsleeps to be scared of. weather,smooth,routine and a good pro friends in cockpit have saved me from worse.as i have them,sometimes. so ref,admitting that,i find a very good reason to be against any stretch of duty and flying hours,which seems to be the trend nowadays. we are even now over the human capability in many a ways. I run a business in my present incarnation with brutal hours and a long drive home. What works for me is a strong cup of coffee just before the drive home.
Seems to offer 30 minutes of solid protection and 30 more minutes of pretty good protection. Naps work well too if you can grab them, but the two in combination is even better.

How you get your coffee fix is up to you but flying near the ground in microsleep mode is foolhardy.

aterpster

26th Aug 2014, 01:13

The NTSB is typical of the U.S. Government for the past 30 years, or more.

Naali

26th Aug 2014, 01:54

I hope Machinbird has only 30 minutes drive back home. I guess most of us know what it is after the third night of 14 hours...and a bit tongue in cheek,Cargo terminals very seldom offer You coffee that is younger than You.

porterhouse

26th Aug 2014, 20:26

It is YOUR "independent" Safety Board:
Is this nstb history fair play? NTSB probably did the right thing.
The last thing you want during investigation are squabbles between two parties both issuing public statements. And there was no need to kick out anybody else who participated constructively in the investigation.
And YES, NTSB has been very independent, its track record is spotless.
Pilot's Union is a highly politicized organization, would be at the very bottom of my trustworthy list, I won't shed tears because of their "non-participation".

Huck

26th Aug 2014, 21:01

Pilot's Union is a highly politicized organization, would be at the very bottom of my trustworthy list

...And you're on a professional pilot web board saying this?

As if the other parties have no dog in the fight..... Beer me strength....

tdracer

26th Aug 2014, 23:41

I've worked with the NTSB on accident/incident investigations, and I've seen absolutely no evidence of bias or impropriety.
However, the FIRST thing we were told at the beginning of the investigations was that we were not allowed to publically release ANY information with regard to the investigation until the NTSB had issued their report - we were even discouraged to discuss it with co-workers other than to get additional technical input. Failure to abide by those instructions by an individual would result in severe discipline - including being fired. One of the most difficult parts for me when I was investigating Lauda was that I couldn't talk about it to anyone (it had quickly become obvious we'd collectively missed something that allowed the T/R to deploy and cause the crash, killing hundreds - and that was not something I easily internalized).

the NTSB wrote that both IPA and UPS took actions prejudicial to the investigation by publicly commenting on and providing their own analysis of the investigation prior to the NTSB's public meeting to determine the probable cause of the accident.The NTSB did what they said they would do at the beginning of the investigation. I have zero problem with that. To have turned a blind eye to the misbehavior of the pilots unions would have been the NTSB showing bias.

DozyWannabe

27th Aug 2014, 02:07

So, of course then the NTSB does NOT revoke the USA's manufacturer's Party Status:
To be fair, there's a considerable difference between a technical briefing regarding improvements to avoid a system failure which was already public knowledge and what amounts to leaking details of an ongoing investigation which have not yet been made public.

Similarly, NTSB did NOT revoke their big manufacturer's Party Status after the famous Boeing Scenario (http://x.co/5Kk8v) was proposed in the summer of 1979 (http://x.co/5KpQX).
The H. "Hoot" Gibson incident again - really?

In that instance the lead investigator may have accepted Boeing's conclusions, but let's not forget that the NTSB summarily rejected Boeing's proposed scenario regarding the 737 rudder hard-over problems.

NTSB has been very independent, its track record is spotless.
Not quite, it has stumbled a few times since being granted independence - but overall its record is pretty solid.

DozyWannabe

27th Aug 2014, 19:46

with the respected manufacturer's submission leading the poor NTSB staff -- and then omitting the crucial information that might properly reveal the design-weakness.

With all due respect, I think you're letting your (justifiable) bad feeling regarding the Gibson incident lead you to assume that all investigations follow a similar path, when that's not the case. Obviously in that case, the lead investigator didn't follow up with enough vigour on the alternative propositions put forward, however that was but one investigation.

As I said above, the NTSB investigators of UA585 and US427 summarily rejected Boeing's proposal that the B737 rudder hard-over could be caused by inadvertent pedal manipulation by the crews concerned.

(eg, ntsb's Bob S. during the TWA800 investigation deserves recognition for his work)

He credited the UK AAIBs methods on the PA103 investigation as the basis for all the reconstruction-based analysis work the NTSB did there. Not denying it was a good bit of investigative work though!

In the thread-item about mid-way down, notice that the Boeing Submission subtly avoided discussing those failures in the automated features of the Electrical system -- then the NTSB Systems Engineer completely missed those technical problems omitted from the Boeing Submission

To be fair, you make a few assertions that ring a bit amiss:
Recall the basis of the 2-Pilot concept: No Flight Engineer , no 3rd pilot would be needed in the B767 Cockpit (Douglas was working the MD80 development at the same time)

In fact the DC9 (from which the MD-80 series was developed) had *always* been designed around a two-person flight deck, as was the Jurassic B737 and the BAC One-Eleven. A 2-person crew has been nothing out of the ordinary in short-haul ops since the mid-'60s.

With reference to your talk of certification in that post, remember that as a derivative of the original DC-9 (as with later generations of the B737) the MD-80 is, I believe, given "grandfather" rights from the original 1960's certification regime for the DC-9, and thus is exempt from later regulations strengthening certain aspects of safety and redundancy.

It's also worth bearing in mind that whatever your feelings on the matter, Human Factors is a much better-understood aspect of investigation than it was in 1979.

If you take these factors into account, you can see why the St. Louis MD-80 investigation followed the path that it did - not, in my opinion, because of subtle shenanigans on the part of the manufacturer but because a central aspect of the aviation infrastructure allowing airliners to be given "grandfathered" certification from earlier variants is that the manufacturers' maintenance and operating procedures must be followed precisely, which they were apparently not in this case.

tdracer

27th Aug 2014, 20:21

IGh, you totally ignored the primary focus of my post. The pilots unions were excluded from the NTSB investigation because they broke the rules. I find it very hard to believe that these unions were unaware of and hadn't agreed to the non-disclosure rules up front - which means that what they did was knowing and intentional. And that is inexcusable.
It's simple - play by the rules, or be excluded. How can you find fault or accuse the NTSB of bias for following their own rules?

AirRabbit

28th Aug 2014, 20:35

tdracer calls our attention to a couple of factors … the FIRST thing we were told at the beginning of the investigations was that we were not allowed to publically release ANY information with regard to the investigation until the NTSB had issued their report - we were even discouraged to discuss it with co-workers other than to get additional technical input. Failure to abide by those instructions by an individual would result in severe discipline…

… IGh calls our attention to other factors … … There were several other comment-ers here, who stated that they hadn't noticed any weakness inside NTSB investigations. These investigator-errs are mostly subtle, with the respected manufacturer's submission leading the poor NTSB staff -- and then omitting the crucial information that might properly reveal the design-weakness…

… and Dozy directs our attention to other slightly different factor … …(w)ith all due respect, I think you're letting your (justifiable) bad feeling regarding the Gibson incident lead you to assume that all investigations follow a similar path, when that's not the case. Obviously in that case, the lead investigator didn't follow up with enough vigour on the alternative propositions put forward, however that was but one investigation…

…and I fully recognize the accuracy of IGh’s comment that … this verges into a thread-drift away from any UPS mishap…

..but, I believe these comments ARE well-meaning … and, unfortunately, accurate – at least enough times to be aware that they exist. So, with any apologies that might be thought to be appropriate, I think that the point being made here IS, the following:

1) any (…and I mean ANY…) governmental organization or any company where there is … or there is the potential for there to be … severe scrutiny by “outsiders” … particularly when those outsiders are in a position to register objections or express disappointment or disapproval of whatever is or has been done, including the process used and what is or is not considered … (particularly if the “higher-ups” within the organization being complained about either are or could be concerned about continued funding, continued staffing, appointment reconsideration, or even “re-election” if those objections, disappointments, or disapprovals are allowed to progress) …

2) it is almost guaranteed that the issue is very likely to be downplayed, expressed in a manner that it might be overlooked or unrecognized, or, in some cases, re-worded in such a way that one could continue to argue for its retaining its initial meaning, or finally, in extreme situations, even “inadvertently omitted,” but, in any event, if presented at all, could easily be read and/or interpreted with a much lower level of recognition or concern as having had any large degree of influence on whatever happened.

It might be necessary to re-read the above thought to understand the point I’m attempting to make. From my perspective at least, the above kinds of situations happen with at least some frequent regularity. Again, the bigger the cause for the examination, the bigger the “hoopla” that could be generated … and this, more times than not … results in the bigger the “effort” being expended in doing whatever is deemed necessary (any or all of the above) by those who see themselves as having to make the largest correction, or those who might be “hurt” or “embarrassed” (or both) to the largest degree.

The fact is that sometimes, very well meaning professionals are either swayed by some aspect of an investigation, or are not listened to by that person’s superiors – regardless of the employer. Some people examine “facts” and reach conclusions that are diametrically opposite the conclusions reached by others looking at exactly the same facts. Some of you may recall the extensive posts I made some time ago regarding the Air Florida, B-737 accident at the 14th Street Bridge, after takeoff from Washington National Airport, Washington, D.C., on January 13, 1982. The same NTSB discussed in this post was the NTSB that performed that investigation. The FAA tower controllers, Boeing, Pratt-Whitney, Air Florida, the pilots flying the airplane, several persons or companies providing ground servicing, and others, were either directly or indirectly involved. Some of the interviews and some of the statements that were gathered did not appear in the report. Some other information that was gathered and did appear in the final report did not play a part in the final determinations or recommendations. Additional information, thought by some to be extremely relevant was completely disregarded. Some facts were included but apparently were not considered to be relevant by some professionals, and other professionals considered those facts to be pointedly relevant.

The point here is that humans are human. And, as we all recognize, humans make mistakes – sometimes those mistakes are meaningful and sometimes they are irrelevant. Unfortunately, we all will not always agree on when any particular decision (regardless of what conclusion is reached) is accurate, partially accurate, or totally inaccurate OR if any specific decision is relevant or irrelevant to the larger issue involved. Knowing all this, it is truly an amazing occurrence when any airplane accident is investigated and any meaningful changes to operating practices are or can be recognized and then made. The only thing we can do is continue to look, learn, look some more, and learn some more … and then apply what we’ve learned in the most advantageous manner possible. And have someone keep a bag packed.

Capn Bloggs

29th Aug 2014, 00:35

Sounds like sour grapes to me. Unless UPS and the IPA directly, publicly criticised the NTSB, why on earth would you lock out the two major players? There must be a long history of knives/back stabbing in the USA for such a "keep your public trap shut until we issue the report" rule to be necessary...

aterpster

29th Aug 2014, 01:08

Bloggs:

Sounds like sour grapes to me. Unless UPS and the IPA directly, publicly criticised the NTSB, why on earth would you lock out the two major players? There must be a long history of knives/back stabbing in the USA for such a "keep your public trap shut until we issue the report" rule to be necessary...

The NTSB is a political hack government agency at the Board level, and has been for many years. (TWA 841, 1979, investigation controlled by Boeing.)

And, even at the investigator level, it is not what it once was because of "PC" hiring and lack of control.

AirRabbit

29th Aug 2014, 16:35

Now the USA's "independent" NTSB suffers the consequences of "unreviewable discretion": no obligation to acknowledge past investigative mistakes, nor "retract" mistakes in any Aircraft Accident Report.
It may or it may not have escaped notice or attention, but the term “unreviewable discretion” does not mean anything other than the fact that the opinions expressed by the NTSB, either as a body or as individual members or staffers, may be expressed without having those opinions reviewed and altered, if required by the “reviewer,” prior to those opinions being made public.

That “unreviewable discretion” does not guarantee that the opinions or conclusions are infallible, or that they include ALL the “facts, and only the facts.” As I’ve said previously, humans make up the membership of the “board,” and humans make up the staff. If that human board member or staffer is convinced (based on his/her background, experience, training, and what he/she saw, heard, or learned during the investigation) that what he/she desires to say is factual (whether or not that “fact” is the whole story or merely a part of it) he/she is authorized to say whatever he/she desires to say … and to do so without having someone else “review” that statement and thereby potentially exert some/any influence on that person to modify the statement or, alternatively, prevent it’s publication.

It has always been my impression that having such an unreviewable discretion “guarantee” would, or at least should, allow any participant to feel completely free to reach and disclose whatever conclusion he/she feels is accurate. Anyone who has ever participated on, or even observed, the public hearings held by the NTSB would and should recognize that everyone offering opinions are welcome to do so – regardless of any bias they may be suspicioned to have.

Of course, the board has set policies and agreements under which all participants allowed/invited to participate (either directly on site or through analysis or other review) are knowledgeable of the agreements regarding release of data or conclusions beyond the agreements they’ve each made. Violations of those agreements should logically be expected to incur consequences – from the most menial through removal from further participation … and that shouldn’t come as a surprise.

However, after saying all this, I also think we all need to note that those persons who DO comply with every aspect of all the agreements, and I include both the board members and the staff members themselves, all are human, subject to all the limitations, tendencies, and inclinations which humans are known to have and which are known to have an effect on human perceptions and understandings. To me, at least, this is the limitation we have to recognize if we allow anyone/everyone who participates in such accident/incident reviews to express opinions with “unreviewable discretion.” I am not sure how to better ensure that the conclusions reached are, indeed, the personal, professional, and considered opinions of the specific individual involved – and that of ONLY that specific individual.

The NTSB is a political hack government agency at the Board level, and has been for many years. (TWA 841, 1979, investigation controlled by Boeing.) And, even at the investigator level, it is not what it once was because of "PC" hiring and lack of control.
Of course, you, as all of us, are free to have whatever opinion you desire – but I think it would be better to couch such as statement as “opinion,” and not some level of “fact.” Of course, I do not know what level of familiarity you may or may not have with any of the NTSB board members or staffers … but I know what my personal level of familiarity is in that regard … I’ve personally worked with 2 of the 5 current board members, and have had the same pleasure to work with literally dozens of NTSB staffers … all of whom have always impressed me with their desire to “do the right thing,” uncover whatever facts can be learned, to provide more relevant conclusions to, hopefully, develop methods, processes, equipment, and/or procedures that will prevent the same or similar circumstances from occurring in the future.

I’m not sure that anyone, anywhere, could have a more sobering or more seriously clearheaded approach to accident/incident investigation. And, it is my opinion that the quality (including the background and experience levels) of those who have become employed at the NTSB over the years that I have been an active part of the aviation system in the US, has regularly, and substantially, improved

And, for whatever value it may offer, I say all of the above with full recollection of the times where I believe I would have reached a different conclusion … and DID … on more than one occasion.

DozyWannabe

29th Aug 2014, 16:38

@Capt. Bloggs, aterpster:

I think you're being a bit cynical there, to be honest.

In this case I don't think it's a case of politics as much as a case of "once bitten, twice shy".

If you cast your mind back to another 1979 accident - namely AA191 - you may recall that an unprecedented level of media interest and pressure regarding the case caused the NTSB to have their lead investigator hold a press conference which identified a broken engine mounting bolt as the primary causal factor of the accident before their metallurgist had been given a chance to inspect it. Before long, it became apparent that the bolt had fractured on ground contact, which caused the agency considerable public embarrassment when they had to make another announcement that they were wrong.

It's therefore entirely unsurprising that they henceforth put much stricter rules and guidelines in place when it came to releasing information to the public - particularly prematurely.

What we seem to have in this case is the pilots' union making a premature public statement and the airline representative rebutting that statement - which both parties had agreed not to do before the official report was published. The risk of this kind of premature release of information undermining the credibility of the investigation is very real, as AA191 proved, and for better or worse, I believe the NTSB are justified in the sanctions they gave those parties.

AirRabbit

29th Aug 2014, 17:33

Reference post #219
Very well said, my friend!

barit1

29th Aug 2014, 18:02

DozyWannabe:...caused the NTSB to have their lead investigator hold a press conference which identified a broken engine mounting bolt as the primary causal factor of the accident before their metallurgist had been given a chance to inspect it. Before long, it became apparent that the bolt had fractured on ground contact, which caused the agency considerable public embarrassment when they had to make another announcement that they were wrong.

It's actually a bit more embarrassing than that.

Ravenswood Airport was right on the NW boundary of ORD, and while it had been closed for some time, there was still a hangar containing parts for light aircraft. The DC-10 ploughed into that old hangar.

The broken bolt was actually a Cessna or Piper part.

And the official who made this bogus pronouncement was Vice Chairman of NTSB, E. T. Driver

DozyWannabe

29th Aug 2014, 18:16

Cheers. :ok:

Another thing that's bothered me about some responses is the snarky-sounding references to political correctness. Desert185's post #174 gives the distinct impression of a belief that if the F/O had been a guy the accident may not have happened. I'm at a bit of a loss as to what aterpster is trying to say about NTSB hiring practices.

Look - the reason large organisations have developed affirmative action processes when it comes to hiring is because it was proven beyond a shadow of a doubt that, left to their own devices, managers of a certain gender and ethnic background were predisposed to hiring candidates of that same gender and ethnic background. Suitability for a job primarily hinges on two things - qualification and experience. Therefore it follows that if managers are predisposed to hiring employees of their own gender and ethnicity, then the end result would be a paucity of experience in candidates of other genders and ethnicities, regardless of qualifications. *That* is why these practices were put in place - to redress the balance in experience.

@barit1: I don't doubt that you're correct in some of what you're saying, but as I understand it, the apparently "sheared" engine mounting bolt was recovered from the runway, not from the hangar. As such, it was unlikely to have come form a Cessna or similar aircraft.

aterpster

29th Aug 2014, 22:20

Dozy:

I'm at a bit of a loss as to what aterpster is trying to say about NTSB hiring practices.

Let me help:

The NTSB has hired some fine female aviation investigators. They are cut from the same cloth as the male investigators of times past; i.e., they had flying in their blood and aviation experience when they hired on at the Board.

In more recent years this pool of qualified female candidates became depleted. So, to fill quotas the Board hired females to be aviation investigators who had zip aviation background. They were given aviation training at government expense.

The product of this program is a range of newer investigators who work from home and often don't even go to the accident site because they don't like either the effort or the gore.

DozyWannabe

29th Aug 2014, 22:22

With respect, I'd like to see some supporting evidence for this assertion before I accept it.

One thing I know about the NTSB is that their investigators may be hired from other backgrounds than piloting initially, because they tend to want investigators to be "all-rounders". This is different from the UK AAIB, who tend to hire groups of specialists in certain areas.

I'm certainly aware of many old NTSB hands who've done stellar work without going tin-kicking from the past though, so I'm a little sceptical that this is in fact an issue.

Huck

31st Aug 2014, 11:54

Desert185's post #174 gives the distinct impression of a belief that if the F/O had been a guy the accident may not have happened.

The captain was the subject of that comment as well....

Chu Chu

31st Aug 2014, 12:38

Using gender-based hiring quotas would be illegal in the U.S. Federal government. I can't prove it's never happened, but if it were widespread, it would be almost certain to come out. But there are plenty of other problems with the Federal hiring process.

Naali

1st Sep 2014, 20:16

reading some,i find it a gift,to be living in scandinavia.

Smott999

2nd Sep 2014, 13:44

I thought the Captain was the subject....

UPS Crash Probe Raises Pilot-Rest, Training Concerns - WSJ (http://online.wsj.com/news/articles/SB10001424052702304500404579127740983530528)

Lonewolf_50

2nd Sep 2014, 15:48

If I remember correctly, aterpster has had non-trivial amounts of face to face exposure with NTSB over the years, to include during accident investigations.

His PoV ought not be dismissed by those who have not seen what he's seen.

Dozy, post #219 was well said. :ok:

DozyWannabe

3rd Sep 2014, 00:01

...aterpster has had non-trivial amounts of face to face exposure with NTSB over the years
...
His PoV ought not be dismissed by those who have not seen what he's seen

Oh sure, I'm not denigrating his experience at all. In fact we had a bit of a chat via PM and while I still disagree with the conclusions he draws, I can understand why he draws them.

tdracer

3rd Sep 2014, 01:20

With all due respect to aterpster - and with the disclaimer that the NTSB personnel that I've dealt with have been male, my experience is just the opposite - there are far more dedicated female participants in the aerospace and aeronautics field than ever before.

When was in college (Aero Engineering), I could count the total number of females in our class on one finger (there were roughly 30 males). Today, while it's not quite 50-50 with males still in the majority, it's close.:ok:
I've seen a similar response at Boeing - 35 years ago, the percentage of female engineers was single digits (granted, most secretaries - sorry, "Office Assistants", and tech aids were female). Today, it's more like 1/3rd of the engineers female, in some areas over half. Further, most are very good engineers and show a passion for airplanes. It's also been my experience that there is a small percentage of 'dud' engineers among the females.

As noted, I've not dealt with any female investigators in the NTSB, but several of my counterparts in the FAA are female, and they are every bit as good as their male counterparts - in some cases even better.

aterpster

3rd Sep 2014, 14:01

As I pointed out in a private message the NTSB has some very able and competent female field investigators. One I know of went on to run the former LAX office.

The good females, just as the good males, came to the NTSB with some fair amount of aviation background.

The issues are two-fold. The government closed the field offices and told the investigators to work from home. A few years before that they instituted a program to hire women off the street and then paid for them to learn to fly. The motivations tend to be different when you don't have aviation in your blood, so to speak. I saw it at my airline when the non-pilot flight engineers were paid to get a commercial certificate and instrument rating.

The conclusions I have reached with respect to the NTSB have been provided by a retired investigator who was with them for 20 years. I've known him since we were both "pups" at our local airport.

Mr Angry from Purley

3rd Sep 2014, 18:59

I presume when the final report comes out we'll get a view on the roster flown.
The Captain said he had a real good sleep in the Hotel and then the rest room.

Airbubba

3rd Sep 2014, 21:53

I presume when the final report comes out we'll get a view on the roster flown.
The Captain said he had a real good sleep in the Hotel and then the rest room.

The Captain did a phony (according to his wife) sick call for the first three days of the trip. The Captain had previously had a company hearing for excessive 'sick' calls.

From the accident docket:

About 1745, the PF called UPS crew scheduling and reported being sick, cancelling his trip scheduled to begin on August 10. He told the crew scheduling technician that he would pick up his trip in SDF scheduled on August 13. PED activity resumed at 2259 until 2322. According to his wife, she and the PF attended a family reunion on August 9-11 in Catawba, South Carolina, about 30 minutes from where they lived.

quoted text above from page 4 here (the url title seems to come up wrong):

Document 43 ATC 3 - Attachment 1 - BAA - ATC Airport Emergency Operating Procedures Letter of Agreement Filing Date December 16, 2013 4 page(s) of Image (PDF or TIFF) 0 Photos (http://dms.ntsb.gov/pubdms/search/document.cfm?docID=409649&docketID=55307&mkey=87780)

The captain was the subject of that comment as well....

As I reported here a few days after the BHM crash:

There are rumors, I stress rumors, of significant prior crew training issues, if so, I'm sure this will come out in the NTSB report.

http://www.pprune.org/tech-log/521370-ups-cargo-crash-near-birmingham-al-15.html#post7997131

Adjusted employment and training standards to promote diversity and inclusivity are a touchy subject. In the FedEx 647 MD-10 gear collapse in 2003, the pilot flying had significant prior training and job issues.

From an archived PPRuNe thread:

Airbubba 27th May 2004 12:19

>>"They indicate that at the time of the accident, Sclair was undergoing a company-mandated multi-leg "line check," or supervised evaluation, after deviating from an assigned altitude over England a month earlier.

The report reveals that Sclair, with FedEx since 1996, had received two previous unsatisfactory proficiency ratings on MD 11s in 1999 and 2001, but had received additional training and received satisfactory ratings both times.

Interviews the NTSB did with an unidentified FedEx pilot indicated that she had been late to work three out of 10 times in August and had received an advisory letter from company officials on Dec. 8 warning against tardiness. In 1994, an unidentified previous employer indicated unsatisfactory proficiency ratings that year were the result of Sclair's "generally poor airmanship"<<

In fairness to Ms. Sclair, she may have been hired at a much lower experience level than her male colleagues to promote gender diversity, a common practice in the U.S. aviation workplace. A few "unsatisfactory proficiency ratings" from a previous employer would normally keep a non-diverse male applicant from being hired at a major carrier, even a cargo operator like FedEx. U.S. airlines have been required to do background checks including training information for the past several years.

PPRuNe Forums - FedEx MD-10 MEM (http://www.pprune.org/rumours-news/print-131661-fedex-md-10-mem.html)

As referenced in the post quoted above, according to the FedEx 647 NTSB report, before being hired by FedEx Ms. Sclair had significant training problems:

A review of the first officer’s employment, flight, and training records revealed that two of her DHC-8 captain proficiency checkrides (on April 7 and 13, 1994, while she was employed by Mesaba Airlines) were unsatisfactory. According to Mesaba Airlines, the check airman who conducted both proficiency checkrides indicated that the unsatisfactory results were because of “generally poor airmanship.” As a result of the first officer’s unsatisfactory performance during the April 13 checkride, the FAA inspector who observed that checkride required her to be reexamined for her ATP certificate by an FAA check airman under the provisions of 49 CFR, Chapter 447, Section 44609 (currently codified as Section 44709)

Rather than recommending raised training and employment standards, the FedEx 647 NTSB report suggested that additional remedial training programs be created to help those of us who have poor flying skills:

Require all 14 Code of Federal Regulations Part 121 air carrier operators to establish programs for flight crewmembers who have demonstrated performance deficiencies or experienced failures in the training environment that would require a review of their whole performance history at the company and administer additional oversight and training to ensure that performance deficiencies are addressed and corrected.

http://www.ntsb.gov/doclib/reports/2005/AAR0501.pdf

I predict the NTSB will once again not call for raised training standards since that would be unfair to folks who aren't very good pilots. Hope I'm wrong, the UPS 1354 report should be released along with the new iPhones in the next few days.

The question of whether cargo pilots and planes should be held to the same regulatory and safety standards as passenger airline pilots and planes has been long debated here and elsewhere. I'm sure the BHM accident report will soon add to the conversation.

GlobalNav

9th Sep 2014, 16:24

Personal opinion of course.

But I think some other points, perhaps more difficult to get consensus on, should have been made.

1. The use of vertical speed mode to accomplish CDFA on a non precision approach is very bad idea. It amounts to an open-ended descent, totally relying on pilots to stop the descent. VS mode is not recognized by any aircraft system, EGPWS, FMS, AP, etc as an approach mode and unable to trigger appropriate alerts or callouts.

2. Failure of the FO and the Capt to make or back up required altitude callouts, including minimums was a primary cause, not just a contributing factor.

3. NTSB's desire to have the best TAWS software on board is fine, but fails to account for the totally inadequate pilot response to the Sink Rate alert - presumably IAW UPS procedure for the Caution level alert. So, All terrain and vertical speed related alerts below 1,00 ft should be warnings, not cautions, and the pilot response must be an immediate CFIT maneuver. (By the way, I agree that even with enhanced software and alerts, we cannot decisively conclude the crew would have responded adequately.)

4. The NTSB recommendation that all nonprecision approaches be flown as CDFA over reaches in some cases and is otherwise inadequate. Sometimes (admittedly a minority of cases), the dive and drive is the best way to fly a nonprecision approach. CDFA by itself, while well meant, can be a bad idea if done by hazardous means, such as using the vertical speed mode. What NTSB, in a perfect world, should have recommended is that nonprecision approaches be replaced by precision or precision-like approaches as much as possible. The NTSB, today, failed to acknowledge what we learned in the February hearing - that UPS crews fly a minuscule percentage of nonprecision approaches - which leads to lack of proficiency, especially in recognizing errors. The crew ought to be able to fly all approaches with similar flight deck procedures, looking for similar cues, similar sequences of events etc., similar CRM and the on board systems are aware that the automation is actually flying an approach and able to make appropriate automatic callouts.

IcePack

9th Sep 2014, 18:44

Trouble is 98% are taught to fly NPA using FPA or V/S with automatics engaged as really there is no option if not doing a dive & drive. Problem is pilots are supposed to know what they are doing. But of course authorities do not take into account human factors like fatigue stress etc etc

Capn Bloggs

9th Sep 2014, 23:07

The use of vertical speed mode to accomplish CDFA on a non precision approach is very bad idea. It amounts to an open-ended descent, totally relying on pilots to stop the descent.

Only if you don't have adequate procedures. Your charts ned to have a profile to follow, not just "point it down 3.0°" and hope for the best, and you need to have the MDA set in the Altitude Selector (which, incidentally, is what Boeing recommend for my aeroplane). What you do at "100 Above" is up to you with regard to the autoflight, but the ALT SEL will save you at the MDA unless you take positive action to go below it.

ironbutt57

10th Sep 2014, 08:49

It would seem they had "reasonable expectation" in their own minds that they would become visual at a much higher altitude, due to the incomplete met information they had received, and both were probably looking outside...which would account for the lack of any "minimum" calls..

Old Boeing Driver

10th Sep 2014, 09:56

There are 2 things that stand out to me.

First, the fact that they were in V/S mode.

Second, the missed approach altitude was set before they reached a level off altitude, or MDA.

Ian W

10th Sep 2014, 12:34

Just to flag up a 'fatigue' issue that nobody seems to have raised. UPS is pointing out that the crew had time off before the flight. Apparently, several days. I have had to work a considerable time on various 'shift' duties. One of the worst things to do is come off several days off and go straight into a night shift. Some people can cope with that and just pull a long night but others not so much. Indeed the preceding days to get back into having normal diurnal rhythms can make reversion to nocturnal more difficult. Is there any attempt by operators to have pilots prepare for the change to working all night after a period off, or is that left to individuals?

PEI_3721

10th Sep 2014, 16:01

Did I miss this, if so, a link? Possibly a leak / rumour?

WASHINGTON – Today the National Transportation Safety Board determined that UPS flight 1354 crashed because the crew continued an unstabilized approach into Birmingham-Shuttlesworth International Airport in Birmingham, Ala. In addition, the crew failed to monitor the altitude and inadvertently descended below the minimum descent altitude when the runway was not yet in sight.

The board also found that the flight crew’s failure to properly configure the on-board flight management computer, the first officer’s failure to make required call-outs, the captain’s decision to change the approach strategy without communicating his change to the first officer, and flight crew fatigue all contributed to the accident.

The airplane, an Airbus A300-600, crashed in a field short of runway 18 in Birmingham on August 14, 2013, at 4:47 a.m. The captain and first officer, the only people aboard, both lost their lives, and the airplane was destroyed by the impact and a post-crash fire. The flight originated from UPS’s hub in Louisville, Ky.

“An unstabilized approach is a less safe approach,” said NTSB Acting Chairman Christopher A. Hart. “When an approach is unstable, there is no shame in playing it safe by going around and trying again.”

The NTSB determined that because the first officer did not properly program the flight management computer, the autopilot was not able to capture and fly the desired flight path onto runway 18. When the flight path was not captured, the captain, without informing the first officer, changed the autopilot mode and descended at a rate that violated UPS’s stabilized approach criteria once the airplane descended below 1,000 feet above the airport elevation.

As a result of this accident investigation, the NTSB made recommendations to the FAA, UPS, the Independent Pilots Association and Airbus. The recommendations address safety issues identified in the investigation, including ensuring that operations and training materials include clear language requiring abandoning an unstable approach; the need for recurrent dispatcher training that includes both dispatchers and flight crews; the need for all relevant weather information to be provided to pilots in dispatch and enroute reports; opportunities for improvement in fatigue awareness and management among pilots and operators; the need for increased awareness among pilots and operators of the limitations of terrain awareness and warning systems -- and for procedures to assure safety given these limitations.

BOAC

10th Sep 2014, 16:08

Just to flag up a 'fatigue' issue that nobody seems to have raised.- probably because there was no 'fatigue' issue?

Airbubba

10th Sep 2014, 16:33

Did I miss this, if so, a link? Possibly a leak / rumour?

Not sure what you are asking, here's the link from ntsb.gov :

September 9, 2014 - NTSB Finds Mismanagement of Approach to Airport and Failure to Go-Around Led to Crash of UPS Flight 1354 (http://www.ntsb.gov/news/2014/140909.html)

Lonewolf_50

10th Sep 2014, 16:48

- probably because there was no 'fatigue' issue? With warmest regards BOAC ... unless the article cited by PEI_3721 is making stuff up ...
The board also found that the flight crew’s failure to properly configure the on-board flight management computer, the first officer’s failure to make required call-outs, the captain’s decision to change the approach strategy without communicating his change to the first officer, and flight crew fatigue all contributed to the accident.
As a result of this accident investigation, the NTSB made recommendations to the FAA, UPS, the Independent Pilots Association and Airbus. The recommendations address safety issues identified in the investigation, including ensuring that operations and training materials include clear language requiring abandoning an unstable approach; the need for recurrent dispatcher training that includes both dispatchers and flight crews; the need for all relevant weather information to be provided to pilots in dispatch and enroute reports; opportunities for improvement in fatigue awareness and management among pilots and operators; the need for increased awareness among pilots and operators of the limitations of terrain awareness and warning systems -- and for procedures to assure safety given these limitations.
What Ian W seemed to be addressing from my read was the matter of stable circadian rhythm and the challenges of transitioning to a "night/mid" shift if one is coming off of a "day shift" ... a problem not solely faced by flight crews. I have a lot of friends who work oil refineries and off shore rigs. Same problems arise, with attendant safety implications.

Ian W

10th Sep 2014, 17:09

Yes that was my point - and I am not sure if it would be called a 'fatigue' issue in the classic sense but the effects are precisely the same. There are many hours limits and so on - but I have not seen advice on adjusting to nocturnal patterns when the days off you have been given have adjusted you to normal circadian rhythms.

I had the misfortune to work many years of 'rotating' shifts that were summarized as Morning. Evening, Afternoon, Night and some Afternoon-evening, Morning, Night shifts. They are almost guaranteed to lead to a level of push-on-itis where the individual becomes inattentive and just wants to 'get down'.

So the question remains has anyone seen any attempt to deal with this? Perhaps advice to those coming off rest days to start moving into nocturnal rhythms?

BOAC

10th Sep 2014, 17:14

Well, if the NTSB have evidence of 'fatigue' it would be interesting to see it. Remember crews should not operate if suffering from 'fatigue' (in the UK, anyway).

Ian W

10th Sep 2014, 17:26

I believe that the 'evidence' was a deduction from the cockpit voice recorder while the crew were waiting for the cargo to finish loading where both said they were fatigued and discussed the hours changes for pax as opposed to box carriers.

As UPS emphasized quite strongly the crew were coming in from time off! But that is precisely my point, there does not appear to be any acknowledgement that change in waking and sleeping hours causes symptoms that you could argue are not due to fatigue but they are precisely the same lack of attention, loss of situational awareness and cognitive tunneling. There should be some agreed method of moving to night operations after a period with normal days.

BOAC

10th Sep 2014, 17:49

There should be some agreed method of moving to night operations after a period with normal days. - indeed, it would be nice. Having had that 'life-style' for many years it is tiring, but unfortunately 'part of the job'. I cannot see any company shifting working practices without major pressure. 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. Are they going to 'pressure'?

alf5071h

10th Sep 2014, 19:47

Whist fatigue is often associated with night operations; fatigue and sleep are not the same.
The NTSB only comments that there are opportunities for improvement (fatigue management), almost like a passing quip of a current safety item (BOAC :ok:); no factual evidence of fatigue is provided.

Based on the summary, the NTSB provides little of safety benefit for the industry – blame and train, follow procedures, procedures for assurance.
Isn’t it time for the NTSB, regulators, to accept that the industry is encountering accidents which cannot be resolved with old style views of safety and human activity.

Semaphore Sam

11th Sep 2014, 03:03

"As UPS emphasized quite strongly the crew were coming in from time off! But that is precisely my point, there does not appear to be any acknowledgement that change in waking and sleeping hours causes symptoms that you could argue are not due to fatigue but they are precisely the same lack of attention, loss of situational awareness and cognitive tunneling. There should be some agreed method of moving to night operations after a period with normal days."

I started line flying (USAF-MAC) in 1971...I was flying constantly fatigued...the day/night problems were never addressed, EVERYBODY flew tired, some worse than others. In 1978, until 2005, I flew my airline short and long haul...the short haul was even worse, sometimes, than the long haul...(5AM starts until 6PM) rest 24, then 6PM tip 3AM were common). Long haul, with flight engineers, and sometimes double crews, were do-able, but, still, everybody was tired. There were stratergies (with a 3-man crew, one napped whilst the other two watched each other for nodding off; the idiots at FAA said it was illegal, but we did it because it worked), but the day-night anomaly was never addressed...EVERYBODY FLEW TIRED! I'm out of it now, and somehow fatigue was overcome (with numerous close calls; i.e., waking up with rest of cockpit asleep, napping off on short finals, etc...). This is a problem that will NEVER BE ADDRESSED...I suggest y'all jest...live with it, and accept the small percentage of flights, like UPS 1354, that pay the inevitable price. "There but for the grace...." Sam