The NTSB had previously announced that they were going to hold a one day hearing on the crash of the UPS Airbus A300-600 on approach to Birmingham-Shuttlesworth International Airport in Birmingham, Ala., on Aug. 14, 2013.

http://www.ntsb.gov/news/2014/140130.html


Not too long ago, Marketwatch published the following which appears to be a summary of today's hearing:

"NTSB Details Pilot Errors Before 2013 UPS Cargo Jet Crash

Pilots of a United Parcel Service UPS +1.23% Inc. cargo jet repeatedly deviated from mandatory company safety rules and approach procedures just before their plane plowed into a hillside last August near the Birmingham, Ala., airport, federal investigators revealed Thursday."

http://www.marketwatch.com/story/nts...rgo-jet-crash-2014-02-20-194492743

[Edited 2014-02-20 17:51:28]

UPS Crew Complained of Fatigue Before Fatal Crash, NTSB Transcript Shows

" “This is where, ah, the passenger side, you know, the new rules — they’re gonna make out,” Capt. Cerea Beal told First Officer Shanda Carney Fanning, according to a transcript of the cockpit conversation released Thursday by the National Transportation Safety Board.
“They’re gonna make out,” Fanning agreed.
“Yeah, we need that too,” Beal said. “It should be one level of safety for everybody.”
“It makes no sense at all,” Fanning replied, later saying that during a rest period earlier in the night, she woke up and “I’m thinkin’ ‘I’m so tired.’ ”
The transcript was released as NTSB officials held a public hearing Thursday to examine the cause of the early morning crash that killed Beal and Fanning in Birmingham, Ala., on Aug. 14.
Besides crew fatigue, the hearing was focusing on procedures for landing on runways without precision guidance systems, training for such landings, pilot coordination and decision-making, and UPS dispatch policies."
http://www.courier-journal.com/artic...-get-NTSB-attention?nclick_check=1


"The National Transportation Safety Board hearing is expected to highlight a major factor that has not received public attention – that Atlanta-based UPS, the country’s largest cargo carrier, did not upgrade the aging plane’s terrain-avoidance system as recommended by officials at supplier Honeywell International Inc.

The paper reports that UPS said the equipment update was optional, is Federal Aviation Administration compliant, and “there is no way to know” if the change would have averted the crash.

Reuters reported Thursday afternoon the NTSB said “updated software would have given UPS pilots an earlier warning that they were too low before their cargo jet crashed.”

The pilots “did not get a ‘too low terrain’ warning from the plane’s Enhanced Ground Proximity Warning System until one second after the first sound of impact with trees in a residential area during its descent,"
http://www.bizjournals.com/atlanta/m...ort-pilot-error-outdated-gear.html

Quoting PITrules (Reply 1): " “This is where, ah, the passenger side, you know, the new rules — they’re gonna make out,” Capt. Cerea Beal told First Officer Shanda Carney Fanning, according to a transcript of the cockpit conversation released Thursday by the National Transportation Safety Board.

Here we go again. This will be a wonderful debate to see play out again now in the context of a fatigue related cargo operation crash in the US (especially with the irony of that CVR transcript). This will be very interesting to see play out.

Quoting YYZatcboy (Reply 2): Here we go again. This will be a wonderful debate to see play out again now in the context of a fatigue related cargo operation crash in the US (especially with the irony of that CVR transcript). This will be very interesting to see play out.

I hate to see people lose their lives for them to realize that this is a real issue and there really does need to be "one level of safety for everybody" because that's the honest truth. Something has to change, it's sad that it may have taken something like this to make it happen. What will be worse is if something like this has to happen again for them to actually act on it.

It's interesting how we all focus on different aspects of the report.

The one that intrigued me was:

Quote: NTSB staffers uncovered that the commander had what industry and government experts consider a history of training lapses and proficiency challenges stretching back more than a decade. The documents point to several mistakes in simulator sessions, but no accidents or enforcement actions. More broadly, that spotty record raises questions about the effectiveness of UPS pilot-training programs, especially when visual approaches replace automated descents, according to aviation-industry officials.

It is interesting that the industry sets up rigorous training programs but quite frequently seems to ignore the warning signs that the programs generate.

Also:

Quote: On Thursday, the Atlanta package carrier reiterated that its schedules are "well within FAA limits,"

This is just such a stupid thing for UPS to say. Yes, their scheduling is well within FAA limits. But, yes, we have evidence that the crew felt fatigued! There is a problem! Ok, yes, your schedule is legal, but it is just not working, and that is UPS's problem, not the FAA's. I assure you if the UPS makes it the FAA's problem, they are NOT going to like the approach the FAA takes to solving the problem, so they best stop blaming others, put on their big boy pants, and start addressing it on their own!

Quoting Revelation (Reply 4): This is just such a stupid thing for UPS to say. Yes, their scheduling is well within FAA limits. But, yes, we have evidence that the crew felt fatigued! There is a problem! Ok, yes, your schedule is legal, but it is just not working, and that is UPS's problem, not the FAA's. I assure you if the UPS makes it the FAA's problem, they are NOT going to like the approach the FAA takes to solving the problem, so they best stop blaming others, put on their big boy pants, and start addressing it on their own!

Perfectly said.

Quoting Revelation (Reply 4): Ok, yes, your schedule is legal, but it is just not working, and that is UPS's problem, not the FAA's.

So to what extent is it the crew member's problem? Quote from the WSJ article:
"Before starting night duty that extended to almost 5 a.m. the morning of the crash, according to an NTSB analysis, Ms. Fanning opted to spend most of her free time outside her hotel room."

From the WSJ article:

"The cockpit crew exceeded the maximum vertical descent rate for a stabilized approach, failed to verbalize critical altitude changes and violated basic safeguards by continuing the final phase of a descent using limited navigation aids even though the runway lights weren't visible, according to the National Transportation Safety Board. "

This sounds like the conclusions drawn by the NTSB regarding the TWA Convair 880 crash at CVG in 1967.

Quoting hivue (Reply 6): So to what extent is it the crew member's problem?

To the same extent that it's my problem when I show up for work unable to perform. My company monitors my performance, and if it is unacceptable, they do something about it.

What I draw from what I have read is that it is another case, just like the Colgan Buffalo crash, of a captain who should have found another line of work. There are people who are just not cut out to be pilots, just like there are people who should not be doctors, or any other profession. Unfortunately, too often they get too deeply committed to a career that they are fundamentally unsuited for. The airlines are supposed to weed these people out, but on a human level it is very difficult to do. When someone has committed years to get to the position that they are, and have worked for your airline for some time, it is very, very difficult to tell them that they just do not measure up. But unfortunately by not doing so you may be sentencing them to a violent death, and a number of innocent passengers/crewmembers with them. Fortunately in this case there was only one victim. But human nature being what it is, I have no doubt that this will happen again.

Is there an actual report somewhere, or just news stories?

I would be interested also in survivability aspects. Given that the cockpit stayed relatively intact, I was surprised that there were no survivors.

Quoting AirlineCritic (Reply 10): Is there an actual report somewhere, or just news stories?

It is normal for the NTSB to have press breifings before they issue a report.

I think there is no report yet.

Those usually take a lot longer for them to come out.

Quoting AirlineCritic (Reply 10): Given that the cockpit stayed relatively intact, I was surprised that there were no survivors.

The report says that there was an abnormally large vertical descent rate (greater than 1500 fps) so having the cockpit stay intact doesn't guarantee much in terms of survivability.

The picture below is consistent with a high vertical descent rate



Ref: http://www.npr.org/blogs/thetwo-way/...ew-fatigue-eyed-in-ups-plane-crash

Quoting AirlineCritic (Reply 10): Is there an actual report somewhere, or just news stories?

NTSB held a hearing yesterday, viewable here:
http://ntsb.capitolconnection.org/022014/ntsb_archive_flv.htm

NTSB news conference after the hearing:
http://www.youtube.com/watch?v=jW5gmM4yL0Q&feature=youtu.be
(Glad to see the NTSB reiterate they are against the Cargo Cutout)

CVR transcript:
http://dms.ntsb.gov/public%2F55000-55499%2F55307%2F550788.pdf

Quoting AirlineCritic (Reply 10): I would be interested also in survivability aspects. Given that the cockpit stayed relatively intact, I was surprised that there were no survivors.

I don't think the cockpit could be considered relatively intact:
http://assets.nydailynews.com/polopo.../derivatives/landscape_635/ups.jpg

[Edited 2014-02-21 14:22:08]

Sounds like a combination of pilot error and old equipment.

Quoting Revelation (Reply 11): The report says that there was an abnormally large vertical descent rate (greater than 1500 fps) so having the cockpit stay intact doesn't guarantee much in terms of survivability.

They had reduced the descent rate to 500 fpm shortly before impact.

Quoting SEPilot (Reply 9): What I draw from what I have read is that it is another case, just like the Colgan Buffalo crash, of a captain who should have found another line of work.

I don't think we have enough information to say that quite yet.

Quoting rj777 (Reply 13): Sounds like a combination of pilot error and old equipment.

Pilot error likely due to fatigue. The "old" equipment may have been fine if it had been updated as suggested by the manufacturer. That being said, they said there is no way to know if it would have saved the aircraft but perhaps it could have with a warning 6 seconds prior to impact. Who knows, that extra 6 seconds could have made it at least a survivable impact but again, we will never know. What we do know is that fatigue is real and has to be seriously dealt with.

Quoting CF-CPI (Reply 7): From the WSJ article: "The cockpit crew exceeded the maximum vertical descent rate for a stabilized approach, failed to verbalize critical altitude changes and violated basic safeguards by continuing the final phase of a descent using limited navigation aids even though the runway lights weren't visible, according to the National Transportation Safety Board. "

Quoting Revelation (Reply 4): It is interesting that the industry sets up rigorous training programs but quite frequently seems to ignore the warning signs that the programs generate.

I'd be curious to see what exactly his deficiencies and training lapses were. They very well could have been something much less serious than not being able to do a visual approach with no vertical guidance at night, which if he couldn't do that in the sim I'm sure he would have had action taken against him. You can also be the best pilot in the world but when anyone is tired, there is a slower reaction time and less recognition that something is out of the ordinary.

I've been there, I've done it and I don't want to be in the situation they were in any more. Just because I fly boxes doesn't mean my life is less important and shouldn't be protected by the same rules governing a passenger pilot at a major airline.

Quoting SEPilot (Reply 9): What I draw from what I have read is that it is another case, just like the Colgan Buffalo crash, of a captain who should have found another line of work. There are people who are just not cut out to be pilots, just like there are people who should not be doctors, or any other profession. Unfortunately, too often they get too deeply committed to a career that they are fundamentally unsuited for. The airlines are supposed to weed these people out, but on a human level it is very difficult to do. When someone has committed years to get to the position that they are, and have worked for your airline for some time, it is very, very difficult to tell them that they just do not measure up. But unfortunately by not doing so you may be sentencing them to a violent death, and a number of innocent passengers/crewmembers with them.

Being a bit overdramatic, no? The CO was 58 years old so he was probably a competent pilot to have survived that long. If he's that incompetent now, why did they hire him in the first place?

Like Colgan, the problem isn't the people, it's the industry and more specifically the FAA that allows these airlines to run these pilots ragged and then blame them when they auger in a widebody into a field somewhere short of the runway.

One thing that is not mentioned is that the large hill that UPS crashed into is a formidable obstacle which before this incident was not really mentioned on any sort of approach plate or publication. The hill that UPS crashed into is 0.65 miles from the Runway 18 threshold. Rumway 18 has a nonstandard PAPI (visual glide path) angle of 3.28 degrees vice the standard 3.0 degrees for terrain clearance. Even with this steeper than normal glide path, an aircraft will have only 97 feet of clearance over the hill. If the aircraft is slightly low (3 red and 1 white light on the PAPI) there will be only 70 feet of clearance over the hill.

Again, at my company at least, there was nothing in any of our BHM charts to warn us of this significant obstacle prior to UPS 1354.

Quoting 777stl (Reply 16): The CO was 58 years old so he was probably a competent pilot to have survived that long. If he's that incompetent now, why did they hire him in the first place?

Not sure where you are coming from. The article in the thread starter says:

Quote: NTSB staffers uncovered that the commander had what industry and government experts consider a history of training lapses and proficiency challenges stretching back more than a decade. The documents point to several mistakes in simulator sessions, but no accidents or enforcement actions.

So it would suggest he should have had reprimands, if not been fired.

More info:

Quote: n 2000 and 2002, Cerea Beal, then a UPS first officer flying Boeing BA -0.17% Co. 727 jets, voluntarily withdrew from training for promotion to captain, a highly unusual move. The NTSB didn't give a reason for the withdrawal, but government, industry and pilot union sources said that such moves, especially within two years of each other, typically avoid an outright failure. According to the NTSB, UPS told investigators it didn't retain those training records. After working as a co-pilot from October 1990 to the spring of 2009—an unusually long stint by most aviator standards—the former military helicopter pilot became an A300 captain in June of that year, according to information released by the NTSB.

Where I work (not in aviation) my employer ranks employes top to bottom in grade and the bottom 5% are put into a process that makes them prove they are worth keeping or they are let go.

Is anything done like this at the (cargo or pax) airlines?

Quoting bueb0g (Reply 14): I don't think we have enough information to say that quite yet.

What we have is a captain who had voluntarily withdrawn from upgrading to captain twice with a less than stellar record in check rides. While there may have been extenuating circumstances pilots must perform sometimes under very difficult circumstances, and the good ones (Sullenberger, the pilots of UA232, and others) pull the rabbit out of the hat and the poor ones crash. While occasionally good pilots crash, when you have a case where it is clearly pilot error and the pilot has a very marginal record, it is hard to escape the conclusion that had a pilot with a better record been flying the plane the crash would not have occurred. And since my opinion means absolutely nothing to anyone in authority or to the legal process I am not afraid to voice it at this time. I may be wrong, but that is what I believe with the evidence at hand. Ernest Gann described piloting as hours and hours of boredom punctuated by moments of sheer terror. And pilots are paid to deal with the moments of sheer terror, and when they fail, bad things happen.

Quoting Revelation (Reply 18): NTSB staffers uncovered that the commander had what industry and government experts consider a history of training lapses and proficiency challenges stretching back more than a decade. The documents point to several mistakes in simulator sessions, but no accidents or enforcement actions. So it would suggest he should have had reprimands, if not been fired.

Hardly... Again, we don't have enough information yet to draw those conclusions... mistakes in simulator sessions are not exactly rare, and the importance of this data rests greatly on what exactly these mistakes were. That's what a sim is for, it's a place you can safely practice dangerous scenarios, screw up without killing anyone, work out your weaknesses and overcome them. There is nothing that the NTSB has so far released that explicitly states he was a bad pilot or even that the mistakes made in the sim sessions were not quickly rectified.

Quoting Revelation (Reply 18): After working as a co-pilot from October 1990 to the spring of 2009—an unusually long stint by most aviator standards—

19 years as a co-pilot really isn't that long in some places. While command time the world over is probably usually around 10 years, there are plenty of FOs in their 40s and 50s, many in the US, who are in the right seat due to seniority and low turnover rates... This doesn't reflect on their ability in any way, especially as (granting you pass the training) commands are granted based on seniority, bidding and requirement by the airlines, not dished out based on performance.

Quoting SEPilot (Reply 19): it is hard to escape the conclusion that had a pilot with a better record been flying the plane the crash would not have occurred.

Ubsubstatiated and unsupported conclusion. Great pilots can get themselves in crappy situations, and if you scrutinise any pilot's records hard enough, you'll find discrepancies and times when mistakes were made. Flying and flying training is complex and, funnily enough, nobody is infallible and everyone makes mistakes and has their fair share of "oh shit" moments. Most of the time these issues are corrected and lessons are learned. As of yet there is no evidence that suggests this was not the case with this particular captain. I may well be proven wrong but at this stage we don't have enough to condemn him, and as other posters have pointed out, condemning individuals is no help to anyone in any case, especially when those individuals are deceased. Invariably, the real culprit is the system. The system will create its agents (in this case the pilots) and its agents will exhibit the weaknesses of the system; as long as you treat the agents as the problem, there will be more of them. Finding the systemic flaw is the key and allows you to make the system more robust and thereby make the system's agents more robust also.

[Edited 2014-02-21 17:17:23]

Quoting bueb0g (Reply 20): Great pilots can get themselves in crappy situations, and if you scrutinise any pilot's records hard enough, you'll find discrepancies and times when mistakes were made.

Pilots for the most part fly their whole careers without attracting press attention; flying has never been safer, and more people are flying than ever before. It is only when something goes wrong that the pilot makes the news. And it is true that some crashes are totally beyond the control of the pilot; UA232, for example, was caused by an extraordinary mechanical failure. But the pilots still made the news, because by extraordinary skill and some luck managed to bring the plane down under some semblance of control on an airport, when they had no reasonable expectation of being able to do so. Likewise, Sully Sullenberger managed to land his plane safely in the Hudson and save everyone aboard when there was no reasonable way for him to avoid catastrophe. Also, Peter Burkhill (the BA 777) and the pilots of QF32 have shown that skilful pilots can avert what looks like certain disaster. But the Colgan pilots at Buffalo, and apparently the UPS pilots here, took what should have been relatively ordinary flights and turned them into disasters. Coincidentally, the two captains' training records have glaring indications that they should never have been allowed in command of an airliner. This attitude in society that there is an excuse for everything, and nothing is ever anybody's fault, is very destructive, and leads to more and more disasters. Ultimately, there is no excuse for a pilot to fly a perfectly functioning airliner into the ground in ordinary weather, period. When he does people get killed. And the record of airline safety proves that this need not happen.

Here's a NASA report filed by an F100 crew flying the 18 LOC approach to BHM back in 1999 and they felt it was an accident waiting to happen with the high terrain of the hill and trees on final to 18 .

http://www.37000feet.com/report/4370...o-terrain-on-approach-to-runway-18

Like many crashes, there were apparently several factors, with each of their still to be determined contributions.
It is simple to latch onto the fatigue factor as to pilots, especially with the alleged comments on the CVR, that I assume were not during 'sterile' times of flight. This was a flight and the landing time was deep into the night when humans, including pilots, want to be asleep by nature. That may still be a dominate factor here but it needs further investigation.
I wonder too if there was poor CRM, or a conflict that the co-pilot didn't want to challenge the pilot over although they may have been right.
There could be visual issues as to depth perception along with the topography features leaves a thin margin for error or making it.
As far as we currently understand, there were no determination of a mechanical or electrical failure or glitch at the time of landing
Questions have been raised as to the technology on this a/c to assist the pilots, especially near the landing time of flight. One has to wonder if settings for these systems, like for base altitude were off. Some systems may be difficult to use or read, may not give you critical info until too late or require very careful watching and if fatigued one could miss a reading.

I find it chilling that the crew discussed rest rules before crashing. Absolutely tragic.

Without having read all the NTSB releases, have they actually specified the actual causes of death? Was it blunt-force trauma from objects penetrating the cockpit or was rapid deceleration from hitting the ground? Either way, it doesn't sound pleasant and I hope they didn't suffer.

Quoting KC135Hydraulics (Reply 25): Without having read all the NTSB releases, have they actually specified the actual causes of death? Was it blunt-force trauma from objects penetrating the cockpit or was rapid deceleration from hitting the ground? Either way, it doesn't sound pleasant and I hope they didn't suffer.

Cause of death on both was blunt force trauma. I won't post the gory details but here is a link to the .pdf with the specifics on the docket. http://dms.ntsb.gov/pubdms/search/do...D=410012&docketID=55307&mkey=87780

Quoting apfpilot (Reply 26): Cause of death on both was blunt force trauma

If I understood correctly, neither of the Captain or FO were wearing shoulder harnesses. In a situation like this, I'm curious if that could have made the difference between life and death. The FO's seat back had been detached and thrown from the aircraft, so perhaps the impact was just too great anyhow.

Quoting apfpilot (Reply 26): Cause of death on both was blunt force trauma. I won't post the gory details but here is a link to the .pdf with the specifics on the docket. http://dms.ntsb.gov/pubdms/search/do...D=410012&docketID=55307&mkey=87780

Oh wow... thank you very much for sharing this. It was tactful of you to direct me there rather than post the details because of the severity of it. I feel for those two for what they had to endure... very sobering, regardless of the events which may have lead to it occurring.

Quoting CF-CPI (Reply 27): If I understood correctly, neither of the Captain or FO were wearing shoulder harnesses.

They were both wearing their shoulder straps.

Quoting CF-CPI (Reply 27): If I understood correctly, neither of the Captain or FO were wearing shoulder harnesses.

They were both wearing their shoulder straps.

Quoting CF-CPI (Reply 27): The FO's seat back had been detached and thrown from the aircraft, so perhaps the impact was just too great anyhow.

That was after the ARFF crew had extricated the pilots. They had to remove the seats entirely from the cockpit to remove the pilots. Both seats and pilots were fully contained in the cockpit, pre-extrication.

Quoting KC135Hydraulics (Reply 28): I feel for those two for what they had to endure... very sobering, regardless of the events which may have lead to it occurring.

I have to imagine death was near instantaneous, especially for the copilot with her head injuries. I doubt they felt any pain.

Quoting apfpilot (Reply 26): Cause of death on both was blunt force trauma. I won't post the gory details but here is a link to the .pdf with the specifics on the docket. http://dms.ntsb.gov/pubdms/search/do...87780

Thanks for posting that. Terrible.... Hopefully some good can come of it, though, as with any accident like this.  

Quoting PITrules (Reply 29): They were both wearing their shoulder straps.

So much for my reading comprehension. Are shoulder harnesses required during takeoff and landing, or in other situations, or is their use completely discretionary?

Quoting CF-CPI (Reply 32): Are shoulder harnesses required during takeoff and landing, or in other situations, or is their use completely discretionary?

Yes they are required for takeoff and landing, unless they interfere with a crew member's duties.

Quoting tb727 (Reply 15): Just because I fly boxes doesn't mean my life is less important and shouldn't be protected by the same rules governing a passenger pilot at a major airline.

Beautifully stated. Thank you.

Quoting 777stl (Reply 16): the problem isn't the people, it's the industry and more specifically the FAA that allows these airlines to run these pilots ragged and then blame them when they auger in a widebody into a field somewhere short of the runway.

Bravo.

This is an industry that runs people to the brink - and sometimes beyond - the brink and then blames them for it. In the case of fatigue, the fatigue itself interferes with your ability to recognize it and that's a dangerously insidious thing.

Quoting 71Zulu (Reply 22): Here's a NASA report filed by an F100 crew flying the 18 LOC approach to BHM back in 1999 and they felt it was an accident waiting to happen with the high terrain of the hill and trees on final to 18 .

Thank you for sharing, very insightful read. Can't say that the forewarning wasn't there...

The other point that I have yet to see brought up is the crew (within the transcript), indicate several times that ATC were keeping them too high for their preference on approach, which could be the reason for the greater vertical decent. What doesn't make sense to me is that if they had the runway insight, how could they have not seen the hill on approach as well?

^^^ I thought of that too and based off the transcripts the captain seemed to be pretty upset about that as he mentioned it multiple times. Although being held high by ATC is no reason to fly your A300 into the ground, I can see how it added to the complexity of the situation.

Quoting FlyAAS80 (Reply 35): how could they have not seen the hill on approach as well?

It was dark during the final, IIRC. Perhaps that was a factor, on top of the aforementioned fatigue?

That CVR transcript was tough to read, Godspeed to the crew. Does the fact that the autopilot altitude was reset to the missed approach altitude have any blame here? Seems if they left it at the 1200 foot MDA the aircraft would have started to level off in time before hitting the trees.

There is also some audio from BHM tower,

http://youtu.be/IVKttdrIGVA

There was a FedEx out there too but they chose to wait until 6 reopened, just sad all around.