UPS 1354 NTSB Investigation - CVR

[JammedStab]

Originally Posted by ManaAdaSystem

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]

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]

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]

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]

Airbubba:

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

http://dms.ntsb.gov/public%2F55000%2...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]

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]

More effective training on non ILS approaches.

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]

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

[Airbubba]

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]

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]

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]

glendalegoon

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]

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]

The captain was a Marine Corps helo pilot.

[Lonewolf_50]

Originally Posted by tubby linton

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]

Originally Posted by glendalegoon

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]

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

[GlobalNav]

@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]

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]

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.