Looks like they never correctly sequenced the approach in the box, were playing catch up from above with a late descent and V/S ed down through the path into the ground. They weren't stable at 1000 feet and did not go missed approach as required by the procedures. The callouts at 500 feet and minimums weren't made.

I'm thinking they are going to hang the dispatcher for believing that the LOC 18 procedure was not allowed at night and not telling the crew. He implies that he didn't want to insult the crew's professionalism by telling them about it.

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.

There is definitely some CVR commentary on fatigue and the cargo cutout in the Part 117 rest regs.

The big question to be asked is that 1000ft QNH or QFE to which they are referring?. The airport is 650 ft amsl. Crew co-ordination and monitoring seems to have completely broken down as the sop calls are not made and pnf does nothing to catch this error. At the end of another long night the urge to put the aircraft on the ground is very strong and was this the crew's primary motivation.. The FAA is negligent for not including cargo airlines in their new FTL and the crew discuss this before departure. An aircraft when it crashes doesn't know if it contains bodies or boxes.

It's 1000 feet AGL (QFE if you prefer), this 'no flags' callout has been done in the U.S. since at least the 1960's from archived NTSB reports.

Similarly, under the 'no significant loss of life' principle, the fatal UPS BHM widebody crash doesn't even make the Freight Dog forum here on PPRuNe. It is on Tech Log.

http://dms.ntsb.gov/public%2F55000-5...7%2F550138.pdf

- the interior of the cockpit was largely intact
- the floor below the seats had moved up a few inches
- the seats were tilted slighly forward but apparently stayed attached throughout the crash (the CPT's seat and the F/O's seat back were found outside of the cockpit by NTSB consistent with extrication efforts by the firefighters)
- the firefighters saw the lifeless pilots inside the cockpit but could not enter until fires / explosions were brought under control
- by the time they did, the pilots were dead
- the pilots died by blunt force impacts to heads and torsos
- they were wearing full harnesses at the time of impact

So we have a cockpit and seats with almost fully preserved structural integrity (something that would not happen in a similar speed car crash) plus we have a much better restraint system than in a car. So did they hit the instrument panel (unlikely with a should harness) or did some panels come down on them (the report does not say)?

Blunt Force Trauma doesn't necessarily mean that something hit them. It just means that the force was not a penetrating force. Force applied by the seats and harnesses would be "blunt force". It is entirely possible for fatal injuries to be sustained that way. One specific way is through a torn aorta resulting from acceleration forces on the heart.

For those interested:

Discussion of CVR transcript is here.

CVR transcript link is here

@Lonewolfe_50
 

Here is a link (if it works) to the NTSB docket regarding the PAPI's not being certified for aircraft with height 4 (Airbus 300).

http://dms.ntsb.gov/public%2F55000-5...7%2F549056.pdf

Runway 18 PAPI is certified for height group 3.

It is document number 48 on the docket.

@Old Boeing Driver
 

DA2000 corp pilot here. Interesting about the PAPI not being certified for a height 4 aircraft. I have never heard of this before. Digging around the interwebs produced a basic definition. So if I used a PAPI at JFK, assuming it has a PAPI for a height 4 aircraft, would that cause me to land past the TDP for my category?

Old OBeing, thanks, but that doesn't change its utility previous to threshold crossing. ;)

PAPI "Issue" is Irrelevent
 

That the TCH was 47.7 ft, not 60-75 ft, which is the minimum for Height Group 4 (A300), is not relevant to this accident, considering the events, in my opinion.

Had the crew paid any attention to the PAPI, used its advisory vertical path information, the airplane would not have collided with the terrain. Even the beginning of "4 reds" would have kept them safely above the terrain.

The FO and the Captain missed both the 100 ft above and the Minimums calls, at which point the decision to continue or go-around should have been made. At Minimums, if they saw the runway, then the PAPI would already have shown 3 or 4 red lights. So a difference of 13-15 ft of TCH is a non-factor. (This is clear from Figure 9b of the Aircraft Performance Group Report.)

The aircraft crossed IMTOY almost exactly at the 1,380 ft altitude restriction, but at approximately 1,500 Ft/min, or twice the nominal value. Did this vertical rate create a non-normal tempo for the approach after the 1,000 ft (above touchdown) call and contribute to the crew's failure to anticipate reaching minimums?

GlobalNav;
I agree.

I put together the following graphic, similar to mm43's but using G.E. The timings and the altitudes are from the original preliminary report and use a nominal 145kt groundspeed, and could be refined somewhat for IMTOY. The two important lines are the blue and green ones which are the MDA and 3.2° PAPI, respectively.

PJ2

http://batcave1.smugmug.com/photos/i...Gdbk8cG-X3.png

I would be interested to see a GE overlay of the FDR data. No mention was made of a QAR in the testimony and a modern FOQA programme can give a good representation of what happened.
MM43s graph doesn't tally with the FDR in many areas.

PJ2 great diagram. How about the similarities with ‘incident 1’; not only the final flight path shape, but also the other contributions considered.

tubby linton;

The QAR would not likely have survived as it is usually mounted in the electronics bay underneath the cockpit, but I think I know what you meant and I'm in the process of examining the DFDR traces.

safetypee;
Thank you for the link to the "TAWS Saves..." document - very valuable piece of writing I think.

The accident is a classic "Incident 1" from that document, isn't it?, including as you say, all contributing factors.

If I understand TAWS correctly, the aircraft was not within the "TOO LOW TERRAIN" TAWS Boundary as described below.

http://batcave1.smugmug.com/photos/i...-CsxCjRx-L.jpg

PJ2

We use pcmia cards for our QAR data capture. I do not know about their survivability but they look fairly durable. There did not appear to be a fire in the avionics bay so hopefully it would have survived if it had been fitted.

T.L., yes, let's hope so - QARs usually have more parameters and sometimes to greater sample rates and resolutions than the legally-required parameters for FDRs. DFDAU systems are less sophisticated and usually the QAR is another port off the same FDAU that is sending aircraft/system data to the FDR. This aircraft had a separate QAR.

In the end it is still RNP that's needed globally
 

All said and done, ...since at least AL371, AL736, AL737 and before, and through the period of TWA 514 and since, ....it is [real] RNP that is actually needed, to every jet runway. And since the 1990's, GLS/GBAS, which is vastly better than ILS, and significantly less expensive than ILS.

@ tubby linton

The graphic on page 3 of the other thread was originally put together in September last, and when looking at it in the light of the FDR data, the FP is somewhat in error. As someone has already pointed out to me in a PM, I probably transposed 1380 for 1830 when plotting the alt at IMTOY.

I'm currently having a look at the FDR .csv data file and extracting the relevant data to update the graphic.

@mm43

NTSB has done a lot of the work for you in a very illustrative plot, Figure 9b of the Aircraft Performance Group Report. FWIW

URL for NTSB Aircraft Performance Group Report:
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

GlobalNav;

Thank you for your suggestion and link - very helpful indeed. The issue in the flight data is the fact that the FDR stops at 04:47:33.5 while the CVR continues, (as per explanation in the CVR Group Report) until 04:47:41.7 CDT. Getting the timings synchronized, particularly the extrapolation after 47:33.5, was a bit of a challenge without further data. Up to this point I was using an average of 252fps to back-calculate the various distances from either the threshold or the EOR as was stated in the various reports, and wasn't aware of this excellent report.

The GoogleEarth presentation only makes it easier to visualize - my own was also done last September or so from the preliminary work and some guesswork, (crossing altitude at IMTOY for example), using a groundspeed that is typical, about 240fps.

I look forward to mm43's work - his was very helpful in the AF447 threads.

@ PJ2 totally agree with you and look forward to more insightful comments from yourselff, MM43 and others.

@GlobalNav,

Thanks for the link to the Aircraft Performance Study group report. The extra 8.2 seconds of CVR certainly makes a difference!

mm43;

Re, "The extra 8.2 seconds of CVR certainly makes a difference! "

Does it ever!

pj2:


The realization of death is so extremely brief, unlike many fatal CVRs.

Makes tragic sense in the circumstances.

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

Félicitations pour ce merveilleux travail.
Thank you mm43.


EDIT : Perfect With your Update Rumours & News \ UPS 1354 NTSB Investigation-CVR \ #41 21st Feb 2014

Thanks and Congratulations to PJ2's picture in post 1037.

Such pictures (mm43, PJ2) are able by themselves to help air safety, so demonstrative they are:D

So what has been said about the approach plate saying night NA?

Ref pg 37 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

In the Colgan thread a few years back there was much angst about chattering about icing and the need for a 'sterile' flight deck. Not seen that concept raised here. Is it a dead letter?

@mm43,
your post 1051 : Perfect With your Update Rumours & News \ UPS 1354 NTSB Investigation-CVR \ #41 21st Feb 2014
Thank you

At Vertical speed of -25fps
 

@mm43 chart:

From IMTOY to MDA only took 5 seconds,

Then to bottom of clouds, sink rate alert, just 8 more seconds.

Runway in sight, 3 more seconds.

By then the treetops were only 80 feet below...another 3 seconds.

@kenneth house,

... and your point?

mm43, no worries, I couldn't figure out the point of the post either! States the obvious.

I thought I would put out a revised GE version using now-available data.

What I can't quite understand yet is why they maintained 2500ft after the localizer intercept - they were cleared the approach "upon interception" well before BASKN, so he could have descended to the FAF Xing altitude but didn't. It was not a big deal as 200ft high isn't a problem but I wonder what led then to the persistent selection of "1500" on the VS?

I'm sure the final report will have some interesting observations.



http://batcave1.smugmug.com/photos/i...59xFXtZ-X3.jpg