UPS 1354 NTSB Investigation - CVR
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Re post #174
I thought the Captain was the subject....
UPS Crash Probe Raises Pilot-Rest, Training Concerns - WSJ
UPS Crash Probe Raises Pilot-Rest, Training Concerns - WSJ
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.
His PoV ought not be dismissed by those who have not seen what he's seen.
Dozy, post #219 was well said.
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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.
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.
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.
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.
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.
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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.
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.
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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 said he had a real good sleep in the Hotel and then the rest room.
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.
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
The captain was the subject of that comment as well....
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.
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.
>>"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.
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)
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.
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.
NTSB Report - what should also have been established?
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.
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.
Last edited by GlobalNav; 9th Sep 2014 at 16:25. Reason: typo
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
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.
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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..
2 things
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.
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.
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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?
UPS 1354 NTSB report
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.
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.
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Did I miss this, if so, a link? Possibly a leak / rumour?
September 9, 2014 - NTSB Finds Mismanagement of Approach to Airport and Failure to Go-Around Led to Crash of UPS Flight 1354
With warmest regards BOAC ... unless the article cited by PEI_3721 is making stuff up ...
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.
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.
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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?
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?
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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).