The National Transportation Safety board has determined that the fatal crash of UPS flight 1354 in August 2013 happened because the crew continued an unstabilized approach into Birmingham-Shuttlesworth International Airport in Birmingham, Ala. In addition, the NTSB said the crew failed to monitor the altitude and inadvertently descended below the minimum descent altitude when the runway was not yet in sight.
The crash claimed the lives of UPS Capt. Cerea Beal, 58, of Matthews, N.C., and First Officer Shanda Carney Fanning, 37, of Lynchburg, Tenn.
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 Aug. 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.
UPS and the union that represents its pilots, the Independent Pilots Association, both issued statements. Both were reprimanded by the NTSB in August for making statements related to the investigation while it was ongoing.
UPS released the following statement: “UPS places the highest emphasis on safety and we’ll continue to collaborate with our pilots to enhance our safety practices. This accident was a terrible aberration and the company again extends condolences to the families of the crewmembers. We thank the NTSB for its thorough and scientific investigation.
"Based on the facts of the accident, UPS has made a series of safety enhancements:
· Training and standards enhancements on automation, call outs, pilot monitoring duties, stabilized approaches and no-fault go-arounds.
· Enhanced meteorological information available to crewmembers.
· Committed to participate in ICAO’s LOSA (Line Operations Safety Audit) program.
· New standards for flying into Birmingham at night.
· Per our final submission to the NTSB, we’ve also recommended broader industry fixes.
"We will also upgrade our ground proximity warning system software. However, it’s important to note that the investigation showed that the software on UPS 1354 was compliant and that an upgrade would likely not have made a difference in this accident.
"However, it is difficult to understand how the NTSB reached its conclusion regarding fatigue related to night flying when the pilot had not flown in 10 days and the first officer was off eight of the previous 10 days. We believe these facts – and others – don’t support such a finding.
"UPS goes to great lengths to ensure safety in night-time flying. We schedule our pilots to fly about 30 hours a month – the fewest in the industry and approximately half of what a passenger pilot flies (55); we provide 25-50 percent longer rest periods than the FAA requires, and we provide high-quality sleep and rest facilities for our crewmembers.
"This accident underscores the shared responsibility that companies and pilots have to ensure proper rest and to report to work fit for duty.
"UPS has operated a safe airline with night flying for decades, with a history of more than 3.3 million flights and 8 million flight hours. We are taking corrective actions based on the facts of the accident. We hope the industry and regulatory community will, as well.
"UPS is seeing the NTSB’s safety recommendations and findings for the first time today. We will review them and determine how to best move forward.”
The Independent Pilots Association issued this statement: “The underlying problem is that UPS’s safety culture is fundamentally flawed. The company’s safety culture, or lack thereof, was a focus of the Feb. 20 NTSB public hearing. At the request of the NTSB, the IPA professionally surveyed our pilots in March and the results are clear:
"90 percent of UPS pilots believe UPS fails to properly manage fatigue threats/risks to ensure safe flight operations;
"93 percent of UPS pilots report that it is “not uncommon” to fly with fellow UPS pilots who exhibit signs of fatigue;
"Pilots don’t call in fatigue at UPS when they are tired, because they fear retribution – 88 percent say that calling in fatigue at UPS invites adverse scrutiny;
"96 percent have personally been fatigued during flight operations, but failed to call in fatigued;
"But, almost all (95 percent) of pilots think the safety culture at UPS would be improved if there were an effective, collaborative partnership between the union and company in critical areas such as pilot scheduling practices.
"The IPA is calling for a dramatic change in the UPS safety culture. In our submission to the NTSB, we call on UPS to adopt a robust, collaborative Safety Management System or SMS that is recommended, but not currently required, by the FAA. This should include company/union collaboration in critical safety areas such as flight schedules and fatigue risk management. UPS should partner with its pilot employees, not fight them. A punitive safety culture has no place in safety critical industries such as UPS’s global flight operations.”