UPS 1354 NTSB Investigation - CVR
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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.
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.
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There should be some agreed method of moving to night operations after a period with normal days.
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
); 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.
The NTSB only comments that there are opportunities for improvement (fatigue management), almost like a passing quip of a current safety item (BOAC
); 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.
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"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
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
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to accept that the industry is encountering accidents which cannot be resolved with old style views of safety and human activity.
Last edited by olasek; 11th Sep 2014 at 05:34.
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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.
Unless we completely eliminate humans from the cockpits there will always be accidents like this one.
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Keep seeing references to setting MDA in the altitude window...never experienced that procedure as an ALT CAP would cause a rather large increase in thrust resulting in any stable approach becoming unstable...
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Semaphore Sam seems to know quite clearly where the truth lies... flew postal in Europe some years,and mixed it with day ops on different type. hours sure were within limits,no one just never asked you, how do You sleep?-or at all? BOAC,with all respect,maybe You might like to think again. i do not know backgrounds,but i may know what night flying is..at best and of worst of it.
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Adding some..-microsleeps at final sure scared me.i could be awake in this world at Fix,and then fall asleep for a time to wake for inner marker and landing.. Worst i had when my co,tapped me in the arm,and at same moment,Ground prox reminded that I was doing a G/P arm from above,with 1500 fpm down.. and that wasn,t the only fumble i did in those years... -i read with very suspecting and tired eyes,proposals of duty times,to JARs and stringing of the rest periods. People tend to be human,and do not obey times at hotels,-even though numerical rest is fulfilled by a contract. And we do still fly,be tired or not. -I do not know personally anyone who has called ops in the morning and said I didn,t sleep at all last night and I am not fit for my duties as i want to be. Grounding an airplane somewhere for fatigue,is a big issue,and very probably gets You a Frequent-user card for elevators. Up to seventh...
Last edited by Naali; 16th Sep 2014 at 21:53. Reason: clarifications,something added.
Keep seeing references to setting MDA in the altitude window...never experienced that procedure as an ALT CAP would cause a rather large increase in thrust resulting in any stable approach becoming unstable...
Bloggs, I agree with your thought processes entirely, however you may be interested to know that the FCOM for at least one type (Avro RJ) recommends setting the missed approach altitude when conducting constant descent NPAs. The reason being, in part, that if the speed falls to Vmin and the speed protections kick in, the A/P automatically goes to Level Change. If a lower altitude is set in the window, the autothrottles retard and the aircraft dives whereas if a higher altitude is set, the autothrottles go to climb power and the aircraft climbs.
The downside is obvious, if you don't have the MDA set then you are in an unrestricted descent with only the pilots' awareness to keep it all safe. Normally that's good enough of course, but as in the UPS case, sometimes it's not.
The downside is obvious, if you don't have the MDA set then you are in an unrestricted descent with only the pilots' awareness to keep it all safe. Normally that's good enough of course, but as in the UPS case, sometimes it's not.
olasek, #250 agreed, but my concern is that the regulators do not appear to have accepted the fact, or the NTSB based on their investigative style.
In order to keep the accident rate low – accepting current level of human performance, what safety activities should the industry concentrates on; thus perhaps the NTSB could have identified aspects or deficiencies in these.
A further concern could be that a low accident rate alone might not be sufficient to manage public awareness. Other countries might accept that aircraft accidents happen, people die (less than from other causes in their country), but the western world’s expectations, more often biased by media, might well require a reduction in the total number of events opposed to rates.
What would the public reaction have been if this accident had been a passenger flight?
Setting MDA. As above, there can be many hazards hidden in this operation depending on autoflight system design.
Some have a mini flare mode to smooth the transition before the mode change is annunciated; others might capture the altitude even after selecting GA.
A continuous descent has been shown to be safer; GA from MDA, climbing up to the pre-set alt sel.
In order to keep the accident rate low – accepting current level of human performance, what safety activities should the industry concentrates on; thus perhaps the NTSB could have identified aspects or deficiencies in these.
A further concern could be that a low accident rate alone might not be sufficient to manage public awareness. Other countries might accept that aircraft accidents happen, people die (less than from other causes in their country), but the western world’s expectations, more often biased by media, might well require a reduction in the total number of events opposed to rates.
What would the public reaction have been if this accident had been a passenger flight?
Setting MDA. As above, there can be many hazards hidden in this operation depending on autoflight system design.
Some have a mini flare mode to smooth the transition before the mode change is annunciated; others might capture the altitude even after selecting GA.
A continuous descent has been shown to be safer; GA from MDA, climbing up to the pre-set alt sel.
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yah the SOP's we had on the 'bus and Boeing all called for setting go-around altitude in the window, but again we did not do dive-drive approaches...who knows what type of approach these folks were doing, as the flight plan was not sequenced, any vertical guidance from the FMC/FMGS would be unusable...once again the danger of two heads outside and nobody minding the store rears it's ugly head
Another reminder: the note on the approach plate about night use was noted by the NTSB and acknowledged to be an error in the document - contradicting a previously published FAA determination that Jepp did not account for.
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Ian W
There is some evidence now to suggest that Crews working night shifts "manage" rather than adapt to nights. Its likely the crew were suffering from the effects of sleepiness rather than fatigue. In a previous post it was stated the Captain had been sick prior but had managed to attend a family function for 2 days. If fatigue is a factor it doesnt all add up
There is some evidence now to suggest that Crews working night shifts "manage" rather than adapt to nights. Its likely the crew were suffering from the effects of sleepiness rather than fatigue. In a previous post it was stated the Captain had been sick prior but had managed to attend a family function for 2 days. If fatigue is a factor it doesnt all add up
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Having worked nights
Early in my career (not as a pilot!) I can tell you that sometimes coming off "rest" ie a couple days of normal hours can be the worst, cos of course you stay up in daylight hrs to be w friends and family....your inner clock adjusts a bit....then you go back on a midnight shift and your biorhythms hit rock bottom when you're supposed to be awake and alert.
Awful. Can't imagine being in charge of an aircraft feeling like that.
They'd give us a month on day shift....it was 2 weeks before you felt normal...then you'd have 2 weeks feeling good, then back on mid nights and have to flip round again.
Not healthy.
Awful. Can't imagine being in charge of an aircraft feeling like that.
They'd give us a month on day shift....it was 2 weeks before you felt normal...then you'd have 2 weeks feeling good, then back on mid nights and have to flip round again.
Not healthy.
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okc465:
They know when they sign the hiring papers. The pay is very good and the industry is not nearly as volatile as the pax carriers.
Plus, when they get senior there are some day flights that haul second and third day packages.
Some of them adapt to flying on the back side of the clock, some don't do so well. Those who don't commute tend to do a lot better. But, that's true for the entire industry.
As far as their international package flights go, they are no worse than U.S. pax international flights.
How do you provide overnight parcel service if you don't fly at night?
Plus, when they get senior there are some day flights that haul second and third day packages.
Some of them adapt to flying on the back side of the clock, some don't do so well. Those who don't commute tend to do a lot better. But, that's true for the entire industry.
As far as their international package flights go, they are no worse than U.S. pax international flights.
BOAC:
I won't bet against you there. 
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.
Clearly I don't belong here from my nick but.....
For many years I travelled long haul and ULH on business , I felt tired in and occasionally dozed off in meetings , but I could always ask someone to repeat an issue or laugh it off, after all most of the other people at the meeting were in the same boat (another bad similie)
However you guys cant do the 'run that by me again' option can you and as well as fatigue the whole process of long or night flights does impact on your awareness and judgement. I almost built a career on untangling agreements that our lawyers proudly proclaimed -we were up 'til three am concluding this.
So I know that the freighter crews signed up to do a lot of night flying but that doesn't really mean anything because the affects are often subtle and insidious as exemplified by the remarks here about the change of pattern being worse than the long night duties themselves.
So I support the idea of some pressure on the carriers , why ?
1 I don't like to read about guys ( and girls) getting killed by what might have been a trivial oversight in a desk job, not because they are negligent but because of these subtle human factors
2. The safety record of the cargo industry is appalling compared to mainline Pax flights, how many wide body freighters have been written off in the last 5-6 years with little or no public or regulatory action - had these been pax aircraft the news impact would have been a thousand times greater,
3.I live near major airport and I would like to think I don't have one of these 'forgot to set MDA, failed to spot broken flight director, badly stowed freight incidents happen overhead my neighbour hood.
Again ,please Excuse me for butting in....
For many years I travelled long haul and ULH on business , I felt tired in and occasionally dozed off in meetings , but I could always ask someone to repeat an issue or laugh it off, after all most of the other people at the meeting were in the same boat (another bad similie)
However you guys cant do the 'run that by me again' option can you and as well as fatigue the whole process of long or night flights does impact on your awareness and judgement. I almost built a career on untangling agreements that our lawyers proudly proclaimed -we were up 'til three am concluding this.
So I know that the freighter crews signed up to do a lot of night flying but that doesn't really mean anything because the affects are often subtle and insidious as exemplified by the remarks here about the change of pattern being worse than the long night duties themselves.
So I support the idea of some pressure on the carriers , why ?
1 I don't like to read about guys ( and girls) getting killed by what might have been a trivial oversight in a desk job, not because they are negligent but because of these subtle human factors
2. The safety record of the cargo industry is appalling compared to mainline Pax flights, how many wide body freighters have been written off in the last 5-6 years with little or no public or regulatory action - had these been pax aircraft the news impact would have been a thousand times greater,
3.I live near major airport and I would like to think I don't have one of these 'forgot to set MDA, failed to spot broken flight director, badly stowed freight incidents happen overhead my neighbour hood.
Again ,please Excuse me for butting in....