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UPS Flight 1354 crash: Lessons to pilots

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The National Transportation Safety Board released a new 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. (www.youtube.com) المزيد...

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LoralThomas
Loral Thomas 14
When I posted this, there was one "eject squawk" showing. I'm curious, why would anybody want to eject this information? Is it because they just don't like reading about crashes and fatalities? Or maybe the information shown in the video as to why this crash happened isn't of interest to them. I sure as heck hope it isn't because they (the ones who are pilots) are so full of themselves that they think this could never happen to them. We LEARN from these investigations and I, for one, am happy we have the NTSB investigators on the payroll and they took the time to make this video.
joelwiley
joel wiley 4
It may not have been the topic, but the poster. The OP posts daily or more often from the same source. There are a number of contributors who apparently work for the company sourcing their posts and could be part of their job to post. IMHO this using FA as a form of free advertizing for their site.
LoralThomas
Loral Thomas 1
My education continues. Thank you, Joel.
bentwing60
bentwing60 0
Kinda like Airbus.
preacher1
preacher1 2
Loral, I hate to say it as I enjoy your posts but this was first posted over a month ago. It is a wonderful report though.
LoralThomas
Loral Thomas 0
Well, Preacher, somehow I missed it a month ago. Will try to keep my "currency" up! Thanks for your comment.
preacher1
preacher1 3
Actually, unless you have another name, you didn't post this one. LOL
LoralThomas
Loral Thomas 2
No other name - have enough trouble remembering my own! LOL Maybe it was meant to be this way. Gave me a chance to vent. Hate complacency.
cabrerarand
Randy Cabrera 1
Thank you about the video!
Pileits
Pileits 7
Fatigue was also a MAJOR contributing factor in this accident. However cargo carriers were legally exempted from the rest requirements the passenger carriers have to adhere to after intense lobbying from the likes of UPS and FedEx. Why did those cargo carriers want the exemption, nothing other then saving them MONEY.
preacher1
preacher1 2
Fatigue may have been a factor but a good listen to the CVR shows out right complacency. Whether the fatigue contributed to it or not, idk. I know but one thing, on takeoff or landing, you got to be on your game.
DSHartje
Dwight Hartje 4
Excellent video and thanks for shearing this with us!
arunhn
Arun Nair 3
Glad to see NTSB doing this video instead of leaving it up to National Geographic or some other TV channel to create one a few years down the line!
tduggan2010
Tim Duggan 2
I think at 7:30 in the video, the salient point is made: On an Instrument Approach, if you are not completely stabilized by the FAF....AND if at any time below 1,000 feet AGL your rate of descent exceeds 1,000 FPM....MISS the approach.

These are emphatically stressed protocols at my (former) airline.

Excellent video, with one caveat: Am I wrong, or did the makers resort to stock footage of a B-737NG cockpit, rather that showing an actual A-300-600??
preacher1
preacher1 2
They just flatly weren't minding the store, and as the runway was called, I guess they were just going to slop it in.. It did not say as such, but I expect UPS would be similar. As a 135/90 we really didn't have anything on our own but used AA as a guideline and that's what theirs were best I remember.
preacher1
preacher1 1
They showed a cockpit of something. I never saw an Airbus with a stick and yoke, and somewhere just past the 3 minute mark it shows one.
tduggan2010
Tim Duggan 1
Yeah, the A-300 (both the A-300-B4 which I flew, and the two-crew version, the -600) have conventional control wheels. The side-stick concept that Airbus has since adopted began with the A-320 and subsequent.

Indeed....the cockpit of flight deck shots to represent (or "illustrate") in that NTSB short video are of a Boeing 737NG. I have a lot of time in that type, so it was pretty obvious to me....

Seems sloppy for NTSB...I mean, Hollywood will show a Falcon corporate jet taking off, then "cut-to" a Citation on the ramp as the actors exit, presumably after the flight...only pilots notice these details, I suppose....
ADXbear
ADXbear 2
Good report for everyone to not become complacent EVER.. to double check the set up and be sure it represents the charted procedure.. 300 or 30,000 hours, make a series of mistakes will result in the same terrible position.
planedame
Cathy Vajtay 1
license to learn exemplified. Good info well presented.
DSHartje
Dwight Hartje 1
I have spoken to many pilots, and they say they don't like changing the approach close in to the airport. This can cause judgement errors, and has lead to several crashes before.
LoralThomas
Loral Thomas 2
And the main reason for that is the corrections that need to be put into the puters on board. At least the airlines have 2 pilots to perform this task. GA usually has only one and between flying the plane (with Otto Pilot on board) and making changes to their GPS, their attention isn't where it should be at this critical phase of the flight. New technology is fine as long as it doesn't interfer with a pilot's ability to fly the plane and keep his attention where it should be.

And as far as some of the other comments, I use to tell my students whether they were new pilots, instrument pilots or multi-engine pilots, the first thing that will kill them is complacency. The next is lack of currency. No substitution for currency -- get out and fly and work on your weak points.
preacher1
preacher1 1
What gets me is that I have basically been retired for over a year, not flying officially since December. It is simply amazing at what has happened in 6 short months, change wise.
LoralThomas
Loral Thomas 1
Preacher - do you think the Upset Recovery Program mandated for the airlines by 2020, I believe, is going to get these "puter pilots" back into the mix of actually knowing how to hand fly these machines or will the ever changing technology simply use the "pilot and dog" cockpit crew?
preacher1
preacher1 1
Well, not active anymore but they put that out before I quit and as far as what it was designed to do was good. Whether the bean counters will allow it or not is a different story. I doubt you'll ever see it really enforced in anyway cause by 2020 you'll be into another administration and probably another FAA chairman or 2 and if nothing major happens, they will have other fish to fry. I am only glad that the crew I hired last year was a bunch of hand bombers and not have to worry too much about it.
LoralThomas
Loral Thomas 1
I remember posting about Delta and I think a couple others were already sending some of their instructors to do the course. Delta supposedly sent 10. Your right about the new admins by then -- gonna be interesting.

Did you stay dry down there with all this lovely weather lately? Missed me - only got about 4" for 10-15 day stretch.
preacher1
preacher1 1
I'm like you; DAL started right on it and seems like there was one other but I can't remember which one it was. As far as wx. We stayed dry but I had some lakefront property 2 different times. I live on an old river cutoff that kinda got up, but not real near the house.
patpylot
patrick baker 1
this seems to be an arrogance-based accident, one caused by inadequate attention to flying the plane perfectly. When any pilot flies into a peculiar runway such as this one, the responsibility is on them to be aware and anticipate and watch and perform within the risks of the approach. They did not do that here, and look what happened. I have had the job of flying into Saint Thomas, and there are several large items to be aware of and stay aware of , else one will run up the end of the runway and that is very bad. Trans-Carib did that once upon a time, and ruined a decent jet transport aircraft in the process. UPS did that here- pilot error plain and simple, and I am sorry to point that out. Let it be a lesson.
glenalmorean
Glenal Morean 1
To attribute a series of errors reflecting a complex human factors breakdown to a simple narrative of complacency is not a sufficiently robust analysis to prevent recurrence.

Flight data monitoring at all major airlines also reveal that humans don't always comply with stable approach criteria.

More productively, once airborne, how do we recognize and manage the effects of fatigue? How do we teach effective briefing techniques, including specific monitoring 'gates' for the Pilot Monitoring (PM) and intervention
strategies? How do we avoid task saturation and recognize overload in others?

To simply retort that "It couldn't happen to me" isn't a sufficient takeaway.
preacher1
preacher1 1
I don't think anybody is giving it short shrift, but in listening to the CVR, you cannot deny the complacency, for whatever reason. Takeoffs and landings are the 2 most important parts of any flight and sound procedures were just flatly ignored. As a result, it is a good example of why those procedures are there.
joelwiley
joel wiley 1
The target audience of the video may well be the general public in recognition of the public interest that developed after some of the recent accidents. The NTSB's well publicized reports and press conferences were seen by many. This may be a simplified version of the more technical presentations. For the details, follow the full NTSB reports.
devsfan
ken young 1
From this video I submit this question....For the drivers on here...Am I off base by observing that in this adverse flying condition, perhaps the flight crew were more reliant on the computer to do the flying for them rather than using their learned skills as pilots?
preacher1
preacher1 1
If I remember right, they weren't even paying that much attention to the computer were they?
devsfan
ken young 1
The video indicated that fatigue by the first officer was by choice. It was clearly stated there was "excessive cell phone use" during the FO's rest period.
pbvincent
Peter Vincent 1
When it comes to using automation on approaches, trust but verify! Although it was the FO's doing, the fight director wasn't flying the profile the way both pilots thought it should be flying it. I keep my finger on or near the autopilot disconnect button on the yoke for cases such as this. Hopefully every pilot keeps their stick and rudder skills up to an adequate level to take over if something like this were to happen to them.
preacher1
preacher1 1
To me, even though it was there and we may have used it for the heck of it, on auto land I like your Ronald Reagan attitude of trust but verify. I always did and could do a CAT3 standing on my head. Might pucker the seat but we'd get there. LOL. Things were getting pretty bad until that Upset recovery Act came along. Some folks jumped right into it but bean counters prevailed at others. By the time it's a mandate, I doubt it'll even be thought about.
Viperguy46
Jesse Carroll 1
They "kinda" make a good boat!...
Viperguy46
Jesse Carroll 1
Would having to make and 'LOG" say 3 touch and goes every month be to much to ask current pilots? I mean actually fly the airplane without auto everything!
The airlines could use some of their baggage fee's etc: to pay for the flight time. Better yet do it on a regular loaded flight!
preacher1
preacher1 2
Well, " the Upset recovery program came in last year and is mandated, I think by 2020. Some Airlines embraced it and have already started incorporating it. As I said below, bean counters got to the other and by the time it's mandatory, it will probably be forgot if nothing major happens.
preacher1
preacher1 1
In answer to your question, the T&G's would go a long way toward skill polishing.
30west
30west 1
Based upon personal preference and observing the others that I flew with, most of the crews at my airline hand flew the jet to 10,000' to 15,000' before engaging the A/P. And on descent, turning it off at about 10,000'. There were exceptions... late at night, fatigued after a poor night's rest, abnormal situation to deal with, etc.

Most pilots that I know like to "fly" the jet, not just "manage" its systems. However, some get over enamored by the automation and depend on it too much.
preacher1
preacher1 1
I think that "enamored" part and hand flying is just age. We had auto land but I always like to hand fly in/out to about 10 grand. Most cases, I wouldn't turn on AP til we got on top. Some 121 carriers though, require AP's to be on as low as 1 grand on takeoff so it is rough on them. Sounds like here they ignored everything and were really complacent about it. Somewhere in there they called the runway and were just going to slop it in. Somehow that pesky terrain came along though.
30west
30west 1
I am 100% in agreement with your age (generational) viewpoint. On the flip side, when the glass cockpits came of age in the 1980's and well into the late 1990's, it was a tougher transition for the older generation who had decades of steam gauge flying. By the 2000's, most of that transitioning had already been done and hurdle for the gray beards was pretty much behind them.

I think fatigue/back side of the clock flying had a part to play in this accident, as well. As you know, when your tired or dealing with the non-routine stuff that happens, it is the most important time to follow the procedures. to keep you from stubbing your toe or worse as in this instance.
preacher1
preacher1 1
I started on a 707 in 1973 as FE; going to Captain around 81 after retirements, then to a 757 in 1986. That glass cockpit was a trip.
30west
30west 1
I transitioned from the MD-80 series to the 757/767 in the mid 90's, by then the training center had all the kinks worked out of the training program. Also, to make it a more natural transition than on today's all glass cockpits, those 757/767's only had the FMS's to master, no speed tapes or altitude tapes to become accustomed to using, just the PDF displays that were a natural follow on. Transitioning to the all glass cockpit took some getting use to for me.
preacher1
preacher1 2
It was still a trip. I didn't do the 767 until after I retired. I had speced the new one out but delivery was afterward time the mod folks got done with it. In my off time I had typed on CRJ 200 to do some fill in. They had bought one and I came back to fly it awhile and hire a good crew of newbys so I did the 67 while back up there. Once around the pattern and about 1/2 hour on the ground is all that transition took. I got all new crew hired and oriented and stayed kinda reserve until last April. Then besides the insulin, 65 in November killed it all anyway. Word on the street is that Lantas and other once per day insulin going to be eligible for waivers before long so my replacement is unofficially keeping me current in that King Air/CRJ200 and the 767 so I can grab a cert if that waiver comes down.

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