Pilot error causes crash
The fatal crash of a cargo flight which killed the two pilots on board last summer was the result of an unstabilised approach into Birmingham-Shuttlesworth International Airport in Birmingham, Alabama.
Announcing its findings this week, the US National Transportation Safety Board (NTSB) also determined that UPS flight 1354 crashed because the crew failed to monitor their altitude and inadvertently descended below the minimum descent altitude when the runway was not yet in sight.
In addition, the board revealed 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 during the early hours of 14 August 2013. The captain and first officer, the only people aboard, both lost their lives and the plane was destroyed by the impact and a post-crash fire. The flight originated from UPS’s hub in Louisville, Kentucky.
“An unstabilised 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 stabilised approach criteria once the aircraft descended below 1,000 feet above the airport.
As a result of the accident investigation, the NTSB has made a number of recommendations to the FAA, UPS, the Independent Pilots Association (IPA) and Airbus.
These address safety issues identified in the investigation, including ensuring that operations and training materials incorporate clear language for abandoning an unstable approach.
The need for recurrent dispatcher training for both dispatchers and flight crews, and the need for all relevant weather information to be provided to pilots in dispatch and en route reports were also highlighted.
The NTSB also called 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.
UPS Airlines and the IPA were both excluded from the accident enquiry after breaching an agreement not to put their own analysis of the cause for the crash into the public domain prior to the official report.