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U P S Plane Down In Alabama


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I haven't seen an actual weather report, but is there a chance that once at the MDA, the crew found themselves in ragged cloud bottoms and in an effort to maintain visual they became somewhat disoriented, low and impacted the ground? Did they assume the dark terrain ahead was cloud in the visual line of sight and during the short time period involved violate the MDA?

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During a night visual approach if PAPI and VASI are removed, the vast majority of pilots will fly either too high to the runway, or too low.

In this day and age it can in many situations be made relatively straight forward depending on the circumstances. Used to fly into some real black holes with no approach lights Papis/Vasis or surrounding lighting and the runway was not long for the type being flown. And no published approach or navaids of any type. On a nice VFR pitch black night there was not much to see. On a full moon night it wasn't much better. Halfway through the descent we might see a faint light of the destination. Runway lights are dim and may only be powered by a generator. I have seen the first half much dimmer than the second half making the second half look like the threshold.

Anyways, the good news was that it was relatively flat terrain, we had local knowledge and we had the threshold coordinates which were in the GPS and triple checked for accuracy. So on my flights, the plan was to level off at 1500 feet above the airport and turn to inbound track at 10 miles back using the GPS which solved the alignment problem using the CDI or present track versus runway track depending on the GPS. At this point the runway was very difficult to see except as some sort of lights out there. Then we would configure and start a descent at 5 miles back at a rate of descent appropriate to ground speed. Each mile back the actual altitude was read out along with the desired altitude such as "4 miles back 1800 feet should be at 1700 adjust your rate of descent". Just like a PAR. Once at about 1-1.5 miles back, the visual judgement part became much easier for the PF. It avoided unstable approaches.

While ths situation is much different than the UPS one, it is an example of what can be done.

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  • 6 months later...
Guest longtimer

the NTSB is not happy with either the Company or the Union, nor should they be. I can not remember the last time this happened.


NTSB Revokes Party Status of a Union and an Airline for Violating Agreements
________________________________________

August 25, 2014
WASHINGTON – The National Transportation Safety Board has revoked the party status of both the Independent Pilots Association and UPS Airlines from its ongoing investigation of UPS Flight 1354, an A300-600 air cargo flight that crashed on approach to Birmingham, Ala., last August.

The NTSB took the action after IPA and UPS violated the terms of the party agreement that each had signed at the start of the investigation. In letters to each organization, the NTSB wrote that both IPA and UPS took actions prejudicial to the investigation by publicly commenting on and providing their own analysis of the investigation prior to the NTSB’s public meeting to determine the probable cause of the accident.

“NTSB investigations depend heavily upon technical input from the accident parties,” said Acting Chairman Christopher A. Hart. “If one party disseminates information about the accident, it may reflect that party’s bias. This puts the other parties at a disadvantage and makes them less willing to engage in the process, which can undercut the entire investigation.”

Without first consulting with the NTSB, the IPA issued a press release on August 13 providing its own analysis of the accident, “UPS Pilots Call for End of Part 117 Carve-Out on Anniversary of Fatigue Crash,” which is explicitly prohibited in the party agreement. UPS, also without first consulting with the NTSB, posted comments on a website responding to the IPA press release in which it also provided its own analysis.

“It doesn’t matter who started it,” said Hart. “Neither action is acceptable.”

For more than 40 years, the NTSB has had the sole responsibility for disseminating aviation accident investigation-related information from the time of the accident’s occurrence all the way through to the end of its investigation. This practice was put in place in order to prevent any party member from unfairly influencing the public perception of the investigative findings.

The NTSB may grant “party status” to those organizations that are able to provide technical assistance in an investigation. As a condition to being granted this status, parties sign an agreement that explicitly prohibits them from releasing investigative information to the media or to comment or analyze investigative findings without prior consultation with the NTSB. Once the investigation is completed, all such restrictions are lifted.

The NTSB accident report will note that IPA and UPS were removed as parties because each violated the party agreement.

The letters outlining the reasons the NTSB revoked party status and the NTSB Party Agreement are available below:

Letter to the Independent Pilots Association: http://go.usa.gov/mN4Q
Letter to the UPS Airlines: http://go.usa.gov/mN4w
NTSB Party Agreement: http://go.usa.gov/mx6V
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I recall thinking the same thing regarding public statements made by Boeing during the B787's battery issues.

There is a letter from the NTSB to Boeing in the NTSB docket on the Japan Airlines B787 battery fire at Boston. We may also recall, American Airlines breached NTSB protocols (and the "rules of the game") when they downloaded the DFDR data after one of their B757s overran the runway at Jackson Hole.

The endeavour does remind one of what lawyers will sometimes do in placing unexamined or unproven "conclusions" before a witness which will raise the ire of the judge, (who will instruct the jury to disregard the statement in their deliberations), and the opposing team's lawyer (who will strenuously object), but of course the jury has heard the statements and are "peers", not experts.

He who gets his news out first can sway the unwitting but it rarely affects those who know their stuff. Who cares about those who may have opinions but have no special power or influence over real outcomes?

Self-interested statements never work out and it is always a wonder when some corporate lawyer or company representative believes that it can and takes his company into dangerous territory, risking the ire of those who really can make a difference either then or in the future.

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Actually, the NTSB has done this before in the recent past. They barred American Airlines officials after some inappropriate actions surrounding a runway excursion accident in Wyoming in 2011. A few years before that, they barred the air traffic controllers union during an investigation into a midair collision between a light aircraft and a sightseeing helicopter over the Hudson River in NYC.

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  • 2 weeks later...
Guest longtimer

following is a press release from the NTSB



NATIONAL TRANSPORTATION SAFETY BOARD NEWS RELEASE

An independent federal agency



NTSB Finds Mismanagement of Approach to Airport and Failure to Go-Around Led to Crash of UPS Flight 1354
________________________________________

Sept. 9, 2014
WASHINGTON – Today the National Transportation Safety Board determined that UPS flight 1354 crashed because the crew continued an unstabilized approach into Birmingham-Shuttlesworth International Airport in Birmingham, Ala. In addition, the crew failed to monitor the altitude and inadvertently descended below the minimum descent altitude when the runway was not yet in sight.

The board also found that the flight crew’s failure to properly configure the on-board flight management computer, the first officer’s failure to make required call-outs, the captain’s decision to change the approach strategy without communicating his change to the first officer, and flight crew fatigue all contributed to the accident.

The airplane, an Airbus A300-600, crashed in a field short of runway 18 in Birmingham on August 14, 2013, at 4:47 a.m. The captain and first officer, the only people aboard, both lost their lives, and the airplane was destroyed by the impact and a post-crash fire. The flight originated from UPS’s hub in Louisville, Ky.

“An unstabilized approach is a less safe approach,” said NTSB Acting Chairman Christopher A. Hart. “When an approach is unstable, there is no shame in playing it safe by going around and trying again.”

The NTSB determined that because the first officer did not properly program the flight management computer, the autopilot was not able to capture and fly the desired flight path onto runway 18. When the flight path was not captured, the captain, without informing the first officer, changed the autopilot mode and descended at a rate that violated UPS’s stabilized approach criteria once the airplane descended below 1,000 feet above the airport elevation.

As a result of this accident investigation, the NTSB made recommendations to the FAA, UPS, the Independent Pilots Association and Airbus. The recommendations address safety issues identified in the investigation, including ensuring that operations and training materials include clear language requiring abandoning an unstable approach; the need for recurrent dispatcher training that includes both dispatchers and flight crews; the need for all relevant weather information to be provided to pilots in dispatch and enroute reports; opportunities for improvement in fatigue awareness and management among pilots and operators; the need for increased awareness among pilots and operators of the limitations of terrain awareness and warning systems -- and for procedures to assure safety given these limitations.

A synopsis of the NTSB report is available at: http://www.ntsb.gov/investigations/2013/birmingham_al/birmingham_al.html

The full report will be available on the NTSB website in several weeks.
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I think the NTSB has this right. Notwithstanding improvements in how SMS is done, the NTSB's assessment of this accident is a signal that while the industry has acknowledged organizational factors in which for various reasons error and an accident is more likely, the flight crew here, (and in my view in the Asiana accident at SFO and the Air France accident in the Atlantic) must shoulder the largest responsibility for the accident. A descent rate greater than one's height above ground is a sure sign of an unstable approach and action must be taken immediately but this did not occur.

Fatigue made it into the report, and well it should. The one aspect of this that for me rests with the FAA is the acceptance of the notion that freight operations are somehow different than passengers operations. That's simply caving in to the lobbyists for commercial priorities. A thousand feet shorter and one, possible two houses would have been involved in the Birmingham accident; why is that acceptable?

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DEFCON, you are of course correct. We have seen these accidents before.

The NTSB did not let UPS off lightly, though I don't particularly care for the way Robert Sumwalt expresses himself on behalf of the NTSB...he needs to step back from his emotions a bit, though perhaps that kind of talk is what gets attention... [-(

However, what the assessment of corporate risk you have outlined speaks to in plain language is the dispensability of freighter crews along with the acceptance of the possibility that a few on the ground may go with them, then a momentary loss of corporate credibility/prestige before that all goes down the memory hole and its back to business. You see, for those who are in a position to change things it is demonstrably the accepted cost of doing business and won't materially change because the outcomes never come close to home, really.

I believe it should be a requirement for the accountable executive(s) and someone who represents the shareholders to walk the accident field so they can see the outcome up close, smell it and try to get it out of their mind and their suits while they try to regain their composure. I know and have worked with people who manage an airline who have done that very thing. They say that the impressions and the sensations are indelible and deep. They are the best ones to work with when it comes to true change. Once is sufficient.

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J.O., To me this approach is uncontroversial and honest. I think it is necessary with the kinds of traffic growth predictions we are seeing if we are to get the last bit of the graph even lower, particularly after this year, (which proves that one year does not make a trend - I know you know this but some who can make a difference may not).

One should know the results of inattention, neglect or incompetence - it's not as though "the Smith account gets lost, oh well, etc." and that kind of learning can't be done from behind the desk; one has to walk the field.

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"I believe it should be a requirement for the accountable executive(s) and someone who represents the shareholders to walk the accident field so they can see the outcome up close, smell it and try to get it out of their mind and their suits while they try to regain their composure."

I couldn't agree more with that thought and I'd like to add another; the executive suite should be charged with attending the meetings that follow the crash with the families of the deceased.

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I believe.......................

There will always be aircraft accidents as long as aircraft fly with pilots in the pointy end.

The reasons for the accidents can be varied but some are plainly "pilot error", however, the vast majority of active/retired pilots will not publically speak of such things, but if they do so, it will be in hushed tones....and they can always find mitigating circumstances.

To start wishing executives would walk through the crash site may bring momentary solace to some but companies change, executives change......pilots are pilots and the only thing that changes is their level of experience and expertise as well as their ability to garner the intestinal fortitude where they will refuse to operate when they may be put in harms way.

There will always be aircraft accidents as long as aircraft fly with pilots in the pointy end.

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Well, it's a bit pithy DEFCON but damnit, we have to find a way to get the last part of that graph that Boeing and now Airbus keep putting out down to an acceptable level, (for our current, phenomenal technical capabilities).

It isn't as though these accidents are just that, "accidents" - they're not! That word is too loosely used to dismiss what is by many measures now, a preventable occurrence. This one was. And we can't just tell people to "be better" because most of the time, taking corporate risks, like accepting an unstablized approach, work out just fine, until it doesn't. Aviation's funny that way.

Why crews continue a severely non-stable approach when a go-around is indicated is a top challenge for all carriers. I don't believe time, schedule, fuel or other commercial priorities are the main factor in not going around. I think it is pilot-psyche.

When one is dealing with a mess or with a crew member who is expressing discomfort or disagreement, the mentality that "I can do this" must be changed to, "I now have that thirty seconds that I may be wishing I had in two minutes time...". A decision to continue may be perfectly valid, but the question is a personal moment, - a challenge to see if one is satisfying the requirements of the stabilized approach. It doesn't matter who's fault it is, because in the oak chair, the captain & crew are "it".

It would have saved the First Air crew and their dead passengers. It would have saved the Birmingham crew and the Asiana crew. It would have saved the Air Blue A321 crew and passengers at Islamabad, (CFIT), the B737 at Jogjakarta crew and passengers, the Gulfair A320 at Bahrain as they were all competent and experienced and continued when everything was saying, 'go-round'.

For those who do flight data work, the evidence is there no matter what the carrier; one continually sees messes that should have been go-around. Most air carriers support their crews in going around. The data, the evidence, the training and the history are all there that support the decision. So what mentality, what psyche keeps the approach going and why?

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Going around because the approach is unstable is an admission that a personal, or professional failure of some sort has taken place. Sim related SB's emphasize the point, I think. In the real world, the pilot may well 'forget' professional discipline in favour of fixing the problem. I know there are a number of pilots that have a deep and irrational fear of the procedure itself, others that seem to be transfixed on completing the approach regardless of the deteriorating situation and yet others that are sloppy pilots on an every day basis, but in large operations where crew don't fly together very often, their sub-standard performance is overlooked and only something that gets whispered about in social settings.

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Going around because the approach is unstable is an admission that a personal, or professional failure of some sort has taken place. Sim related SB's emphasize the point, I think. In the real world, the pilot may well 'forget' professional discipline in favour of fixing the problem. I know there are a number of pilots that have a deep and irrational fear of the procedure itself, others that seem to be transfixed on completing the approach regardless of the deteriorating situation and yet others that are sloppy pilots on an every day basis, but in large operations where crew don't fly together very often, their sub-standard performance is overlooked and only something that gets whispered about in social settings.

Surely you have flown into St John's?? :biggrin1: You can have a very stable approach until.....that damned wind takes the aircraft and almost makes it uncontrollable...and one decides .to .."go-around".....not due to a personal,or professional failure....just Mother Nature. :biggrin2::biggrin2:

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DEFCON, are we (flight crews, ops management, safety people, accountable executives), still that far behind that a go-around is a "personal failure" and egos need soothing with quiet bar talk instead of learning?

I thought it was better than that, but again we can't argue with the data.

Hi Kip;

The "walk through the field" isn't intended to be punishment, so the notion of solace doesn't apply. The goal is cultural change, which means the impact of changing personnel at the top has less impact because, "this is the way we operate..." when it comes to flight safety.

As I mentioned in that post, those who already know the business they're in and the consequences of inattention, incapacity or neglect, don't need a 'walk in the fields' so to speak, and they're by far the easiest people to work with regarding the support of "expensive" safety programs.

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"The "walk through the field" isn't intended to be punishment, so the notion of solace doesn't apply. The goal is cultural change, which means the impact of changing personnel at the top has less impact because, "this is the way we operate..." when it comes to flight safety."

I like the way that statement flows.

I don't know that the failure to abandon an approach gone bad is really a conscious decision on the pilots part, or just instinct & perhaps ego gone wrong, a lack of discipline perhaps? I'm not sure at all what the data may suggest, but I've seen Captains that have zero difficulty making the call for the missed when the F/O is messing up and I've seen other Captains employ the 'I have control' technique to save the approach, which in my view is one area where perhaps some new hard rule prohibiting this practice might be considered. This kind of intervention can be ego driven as much as for any other reason and with the switching duties, a scenario may quickly develop in which the already confused F/O makes a deteriorating situation worse.

I hope no one is offended by my use of the F/O as the source of problems in this example.

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Hi Don,

The solace referred to would be for the NOK when they realize that those that govern the company have had to endure the walk through what is left of man and machine. My statement was not meant to indicate that such an action would give comfort to those that " have the power".

Decades ago , (while in the RCAF), when I lost a friend at 8:30 in the morning after I had bid him goodnight the evening before at 9:00pm I had a wise old man tell me that the only way we can be certain that no accidents occur in the aviation world was to insist that we only do one flight a year and the occupants in that aircraft be the Base Flight Safety Officer and the Chief Check Pilot.......bit of a stretch I know and you will get no argument from me that everyone in aviation, civil and Military should strive for "zero" accidents....but no matter what steps we take, safety wise, there will always be accidents.......that is just a cold hard fact that those in aviation live with.

I commend those that attempt to lower accidents through any means possible but I do not understand those that seem to feel that the deceased pilots should never shoulder the entire blame for some of the fatal crashes we see. Much to the chagrin of some aviators, I do not feel that pilots are infallible, nor do I feel that all pilots will never make a wrong and, sometimes dead wrong decision, that 99.9% of the pilot corps feels they would never make.

Bursting a few balloons here, but pilots are just humans and are not immune to making mistakes and you and I and everyone else knows that as soon as a major accident occurs, the pilot Union will do everything in their power to blame another source as the cause of the accident.

Just my opinion because with the amount of time I spent in aviation I saw, and you probably did too, a few pilots that made me wonder how they ever got as far as they did and I breathed a big sigh of relief when they were removed from their piloting position.

Look at it this way...in another profession.....when you go see a surgeon to have some serious cutting done, do you know what his test marks were when he graduated from "Doctors College"??? Probably not....we take it for granted that he is qualified but as we all know, some doctors are more qualified than others and the same can be said for pilots.........Did he /she score a 10, or a 9, or a 8 or 7 or the minimum acceptable 6??

There is no certainty in any profession ...we have to live with that and an attempt to be totally accident free, (with respect to pilot involvement), in the industry is what we all strive for but unfortunately it will probably never happen.

Kudos to those that come forth with new and better ideas to strengthen Flight Safety and Flight Operations.

PS..Hope the photography is going well. My travelling on the water at 6kts for 4 months is most cathartic :biggrin1::biggrin1:

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Hi Kip;

Re "no pilot infallible", "cold hard facts", "pilots removed from their flying position" and "accidents will continue", we're on the same page. It's because I completely agree with those statements that this kind of discussion is good - no balloons burst here.

But through trying, we got the accident rate down from where it was thirty years ago, and that was markedly down from the '50's. Most of it was due to technological change and understanding weather. The challenge now is precisely as you say, the human factor, and it's demonstrably working. One quick example...thirty-two crews experienced the same pitot-unreliable airspeed failure. It was a log-book entry for all of them but one.

The crash rate is fairly steady, which means when there is an increase in flights over the world, the number of crashes will rise as a percentage. That's where we can knock the horns off the beast before tackling the tougher bits and maintaining a steady number rather than a steady percentage.

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  • 8 months later...

Riveting!

NTSB Releases First–Ever Video Companion to Accident Report

June 1, 2015

WASHINGTON – The National Transportation Safety Board today released an 8-minute video that focuses on the key lessons that pilots can learn from the investigation of a UPS cargo plane crash in Birmingham, Ala., in August 2013.

The video is a first-ever such companion to an official NTSB report. The Board plans to produce other videos in the future on major accidents.

“People consume information and absorb lessons in different ways,” said NTSB Chairman Christopher A. Hart. “This video is another way to reach pilots and aviation safety professionals with the lessons we learned through our investigative work.”

The video is aimed at commercial and other professional pilots, but many of the lessons of the accident apply to every pilot – for example, avoiding unstable approaches.

The video can be viewed here: https://youtu.be/ubrGwanOEvM

The full report can be read here:
http://www.ntsb.gov/investigations/AccidentReports/Pages/AAR1402.aspx

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NTSB Companion vide..." This video is no longer available due to a copyright claim by BostonAirborne.

Appears some of the actual footage of a UPS aircraft is the reason for the claim. I imagine that the FAA will release a sanitized version shortly with the more important commentary.

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Using video to communicate such information is an excellent concept. This video was very well done and communicates the lessons of this accident very well.

In variations on the theme, videos have been used in FDM work for years; it is a very effective way to communicate safety information.

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