UPS 1354 NTSB Investigation - CVR
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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?
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?
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akwood00:
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.
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?
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?
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.
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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.
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.
Dispatcher
@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.
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.
Last edited by GlobalNav; 3rd Mar 2014 at 16:00.
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wood:
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?
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.
Please review the docket and come back to us when you have something constructive to say.
Are you (or were you) a Part 121 pilot?
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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.
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.
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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
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
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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.
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.
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wood:
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.
How many flights does a Domestic dispatcher working a midnight shift at TWA work? What about other 121 airlines?
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.
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"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!
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!
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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?
"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?
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wood:
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.
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?
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.
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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%2F55000-5...7%2F550789.pdf
http://dms.ntsb.gov/public%2F55000-5...7%2F550789.pdf
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flyingchanges:
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.
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.
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.
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.
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.
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tubby:
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.
If your company does this on their own initiative, more power to them.
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.
Jeppesen Chart
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?
"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?
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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?
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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.