On August 14, 2013 UPS Flight 1354 crashed short of runway about 0447 hours during a non precision approach to runway 18 at Birmingham-Shuttlesworth International Airport (BHM), Birmingham, Alabama . The official NTSB reports suggests a combination of errors from both man and machine as the cause for the terrible accident that left two pilots dead and hundreds of dollars worth equipments destroyed. But the primary focus was on the errors in judgment of the captain who was the pilot and the first officer who was his copilot as the root cause of this failure. When all the dusts of this terrible tragedy settled what remained was the question of how we choose to evolve from such mistakes and, simply, what we have learned.
The official NTSB report suggests a series of recommendation which could be adopted as regulations within FAA or guidelines within UPS for the flights to adhere to so that they can avoid such mishaps in the future. One of the groundbreaking recommendations was the fatigue monitoring and awareness regulation for the pilots .
This was in light of the fact that the main cause of this terrible tragedy was the failure of the first officer in completing some of the preliminary procedures involved in flight management. Such a puny mistake from the part of an experienced pilot could only be attributed to her poor fatigue management and fatigue awareness. The first officer has been recorded by the CVR as confessed to suffering from fatigue during the flight.
Recommendations
The official NTSB report suggested the inclusion of a fatigue threat briefing mandatory before each departure particularly the ones during the circadian low (0200 to 0600 hours) or nighttime. This was stated in light of the findings of the investigation that revealed copilot’s troubles in making sound decisions during flight and her incapability in comprehending the actions done by the captain. The background investigations revealed that such incapability could be attributed to the first officer’s fatigue following a poor off duty time management.
The FAA regulations require every pilot or flight crew to report any possible fatigue before the commencement of flight so that he/she may be given sufficient time to relieve the fatigue before their next flight. But since the first officer and to some extend the captain failed to do so, the NTSB report recommends a briefing to reveal the threat of fatigue during flights in nighttime a mandatory regulation
The next important gap to be filled was the lack of communication between the flight crew and the dispatch unit. The dispatch crew during investigation revealed that they did not maintain a constant communication channel between the flight crew as they did not want to disturb the pilots with unnecessary information. The crew was not updated on the weather details or about the non precision approach to runway 18 because of this lack of communication. The NTSB report recommends a dispatcher resource management module that will also include pilots to “reinforce the need for open communication” .
Another recommendation includes the need for briefing the approach procedures between the operators and flight crew once they had been changed so that the flight crewmembers can have a common expectation of the approach to be conducted. This was included in the light of miscommunication within the flight crew and between the dispatch unit and flight crew. The captain inadvertently failed to communicate with the first officer when he switched off the autopilot to begin the manual approach. The first officer struggled to pick up this update while she was doing her job as the first officer.
The need for standardized training documents was also stressed by the NTSB report. The need for consistency between the FAA approved aircraft operating manual and other manuals such as the manufacturer’s guidance related to terrain awareness, warning alert responses etc was also stressed under the New Recommendations category of NTSB report. In the particular case of UPS Flight 1354 the lack of standardized procedural manual with the dispatch and the flight crew caused the captain’s error in judgment about the non-precision approach.
NTSB also suggests a constant weather report to be transmitted to the flight crew to keep them updated about the changes in weather and cloud ceiling.
The last recommendation in this category (New Recommendations) was the need for a better proximity alert mechanism as well as a regulation to equip all aircrafts with proximity warning equipments as well as make it mandatory to switch on such warning sensors prior to flight. Even though UPS Flight 1354 was equipped with a proximity alert system it was not turned on during the flight. The NTSB also suggests an improvement be made in this category equipments so that effective call outs can be observed during harsh times.
One of the previous recommendations were reclassified in this report where the operators were advised to incorporate the constant angle of descent technique into non-precision approach. They were also advised to stress on the preference of such method wherever practicable. The pilots were also advised to work with non-precision approaches wherever possible to help them prepare for events that may require them to use such methods. In the particular case of UPS Flight 1354 the captain was not proficient in following procedures related to non-precision approach. This was due to his lack of experience in dealing with non-precision approaches.
The captain was also unaware about some of the provisions of non-precision approach. And since the dispatch did not think such a situation was possible they did not inform the captain about the changes either. This added to the heap of mistakes that led to the crash.
A brief conclusion of all the recommendations can be given as 1. Need for recurrent dispatcher training that also includes flight crews to bridge the communication gap 2. The need for providing detailed weather report both prior to flight and en route 3. The need for improvement in fatigue awareness among pilots and operators 4. The need for better low terrain warning systems as well as briefing the operators and flight crew about the limitations of such warning systems 5. The need for standardized operational manuals in the possession of the flight crew and operators.
Lessons Learned from UPS Flight 1354
The tragedy of UPS Flight 1354 has yet again reminded the aviation professionals about the shortcomings of air traffic that is still to be rectified. When the protocols and regulations of flights are disposed off as trivial or not followed through strictly great tragedies construe. This fact was highlighted all through the NTSB report as well. Had the FAA regulations as well as UPS guidelines were strictly followed, UPS Flight 1354 could’ve avoided the fatal tragedy that ended the life of two able pilots and wasted hundreds of dollars worth hardware.
The FAA regulations strictly state the need for communication between the flight crew and destination dispatch unit so as to avoid any mid air surprises such as closure of runway or unexpected weather changes. The need for such communication was indicated in the report as the flight crew of UPS Flight 1354 eventually failed to note the lower cloud ceiling than the one initially predicted because of this. The flight crew continued their descent in expectation to see the runway even though the weather conditions prevented this from being plausible.
The first officer made an incorrect sequencing of the FMC and completely missed the callouts from the computer indicating the error. This serious error in following one of the preliminary duties as a first officer from a person who has logged in many successful flight hours could only be attributed to her fatigue than anything else. Here again, the FAA regulations to report fatigue prior to the commencement of flight was not followed by the first officer. She was recorded as saying that she suffered from fatigue by the cockpit voice recorder .
The captain displayed errors in performance as well. The necessity for better training in non-precision approach surfaced during the investigation of UPS Flight 1354. After careful considerations, the NTSB discovered that the captain was not fully aware of the procedures that needed to be done during a non-precision approach. Another major flaw detected by the NTSB investigators was the captain’s decision to change to vertical speed approach after the autopilot failed to capture the glidepath. This was stated as a violation of UPS procedures and guidance. This decreased the time available for the first officer to perform her duties.
“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 Acting Chairman made this remark because of the Captain’s failure to perform the go-by round method instead of dive and drive that he used in this case. This is another example of flight crew disregarding their wisdom, knowledge and regulations to giving into their false confidence and pride.
The captain failed to brief the first officer about the switching from autopilot to manual during descent. This confusion was recorded by the Cockpit Voice Recorder which revealed that the first officer was confused for a moment while she updated herself about the switch from autopilot to manual. The captain did not follow the UPS guidelines about strict communications. He also failed to check the FMC and listen to fault callouts during descent. According to regulation, it is his job to verify whether the procedures done by the first officer has been done perfectly. But in this case, captain failed to do so.
Everything from the beginning of the flight to the failed landing was flawed to some degree. The captain and the first officer disregarded the modicum of professionalism in the cockpit by engaging in loose talk throughout. At the time the dispatch made the unavailability of runway 6 and requested the captain to take the non-precision approach to runway 18, the captain and first officer were engaged in conversations ridiculing the destination airport and their choices. The captain and the first officer forgot to follow procedures in dealing with such change of plans. The mishap with the FMC was an outcome of this disregard for procedures.
The flight crew as well as the dispatch is equally responsible for any successful flight. It is not professional to put the blame on either one. The dispatch had the responsibility to inform the flight crew about the new cloud ceiling which was about 350ft instead of the predicted 1000 ft. But it doesn’t exempt the captain from not confirming this scene. It was his duty as the captain to ensure that the initial weather conditions prevailed at the time of descent.
But putting aside all the blames that had been directed to the flight crew, the UPS cargo company has also received some flak for not updating the ground proximity warning system. An available free software enhancement for the proximity warning system could’ve improved the warning up to as early as 6.5 seconds . This could have helped the flight crew identify their closeness to the ground terrain a lot earlier than during the accident. But the UPS has claimed that they did not violate any FAA regulations and there is no evidence as to whether this update could’ve stopped the tragedy from happening.
But it is sure that the captain could’ve decided to go with the fly-by-round method if he had received the low terrain warning long before the flight hit the tree line before reaching the runway. Another issue that appeared was that the FAA regulations do not make it mandatory that the low terrain warning systems be switched on before the commencement of any flight. Even though UPS Flight 1354 was equipped with such a system neither the crew nor the UPS switched them on during this flight.
The safety of aircraft doesn’t primarily rest on the FAA regulations or UPS regulations. It is quite disappointing to learn that the UPS Flight did not have their low proximity warning system switched on during this flight. The captain and the first officer were not given enough time to go for a recovery maneuver when they heard the aircraft hitting tree lines short of runway. They had to listen to the loud rumbling sound of trees hitting the lower end of the plane to understand what was happening. But such mistakes cannot be completely blamed on the shortcomings of regulations. It is still not apparent why regulations are mandatory to make sure that a sensor is switched on.
With the above statement it is clear that the FAA regulations are not the be all and end all of every action that should be undertaken by an airline company or flight crew to avoid such mishaps. A certain amount of discretion is also needed in dealing with these situations. It should be made mandatory for every airline company to keep their instruments up-to-date and performance ready before the commencement of any flight. It should be made mandatory for every crew member to follow procedures strictly according to regulations no matter how casual the flight may seem.
The first officer’s poor off duty time management points us to the disregard many keeps towards regulations related to fatigue management. It is highly unfortunate that such silly mistakes would become the root cause for a fatal ending. Even though most of these regulations may seem trivial or frivolous at times they are usually well crafted to avoid such mishaps caused by even the slightest of mistakes. And therefore they should be strictly followed even at times they do not seem necessary.
Even though the FAA regulations do not point that the cockpit should be kept as a strict military base, it does note that the captain should maintain an order of decorum inside. The captain failed to keep such decorum inside the cockpit during the flight. His failure to strictly direct the first officer to perform the FMC sequencing and then later check the perfection of the data was the main cause of this terrible tragedy. The casual tone inside the cockpit caused the first officer to disregard procedure and the captain to disregard his duties during the descent of UPS Flight 1354.
This fact directs us to check into the atmosphere inside an aircraft. The situations inside the cockpit that might lead to absence of mind need to be avoided. But the question is whether it is necessary to make this a regulation. The captain could’ve directed his first officer to take extra care in doing her duties and adhering to procedures when she mentioned having fatigue during the flight. The captain could’ve ensured that the first officer was following the procedures strictly as he learned that she is not fully capable to perform her duties.
It should be made a captain’s duty to make sure his crew is capable of dealing with all the duties entrusted to them. The captain could take extra care in dealing with a particular crew member and dealing with his/her performance. In case the captain is ailing from such shortcomings himself, he could entrust this task to someone next in command.
The case study done by NTSB has revealed that the issue behind most of the aircraft accidents is not related to the absence of regulations to keep these systems under check. It has always been the result of human errors in judging the significance of these regulations. It is highly imperative that every aviation professionals identify the importance of these rules and procedures and in relation to their relevance in modern flights. The FAA regulations that include but not limited to 1. Fatigue mitigation 2. Communication between dispatch and flight crew 3. Weather data dissemination 4. Adhering strictly to guidelines as directed by FAA or Aircraft manufacturer, etc need to be given the relevance they deserve. This is what this terrible tragedy demands everyone to do.
References
Aviation Safety Network: Crash of UPS Flight 1354. (2014, September 9). Retrieved February 23, 2016, from Aviation Safety Network: http://news.aviation-safety.net/2014/09/09/ntsb-mismanagement-of-approach-and-failure-to-go-around-led-to-crash-of-ups-flight-1354/
Croft, J. (2014, September 9). Fatigue Figures Prominently In UPS Flight 1354. Retrieved February 23, 2016, from Commercial Aviation content from Aviation Week: http://aviationweek.com/commercial-aviation/fatigue-figures-prominently-ups-flight-1354-conclusions
Hradecky, S. (2013, August 14). Crash: UPS A306 at Birmingham on Aug 14th 2013. Retrieved February 23, 2016, from The Aviation Herald: http://www.avherald.com/h?article=466d969f
Mark, R. P. (2014, September 14). UPS Addresses Lessons Learned from Birmingham Accident. Retrieved February 23, 2016, from AINonline: https://www.ainonline.com/aviation-news/air-transport/2014-09-22/ups-addresses-lessons-learned-birmingham-accident
Mike M. Ahlers. (2014, September 10). CNN. Retrieved February 23, 2016, from http://edition.cnn.com/2014/09/09/us/ups-alabama-crash/
NTSB. (2014). Crash During a Nighttime Non precision Instrument Approach to Landing UPS flight 1354. Washington: National Transportation Safety Board.
World Airline News. (2014, September 11). Retrieved February 22, 2016, from http://worldairlinenews.com/2014/09/11/the-ntsb-blames-the-crew-for-the-crash-of-ups-flight-1354-at-birmingham-alabama/
