Fatal Error! How UPS Flight 1354 Ended in Disaster

You know sometimes you need to make a split-second decision to change a plan only to find out that your new decision only made things much worse. Well, now imagine this is happening to you when you are about to land a plane in the middle of the night. To be alert, being a cargo pilot is a challenging and often wonderful job. Now I haven't been lucky enough to try it myself, but I have many friends who have and although most of them love it, there is no way to ignore the fact that most loading operations are done at night. and that comes with some real challenges.

In the early 2010s there was intense debate in the United States over improvements to pilot

flight

time limitations, and in January 2012, new rules were published. those provided stricter limitations specifically for pilots carrying out passenger transport, but curiously not for cargo pilots. Cargo airlines had successfully lobbied that these new rules would be unrealistic for their primarily night-time type of operation and instead pointed to their own fatigue management systems that they had in place. They negotiated with their own unions now, although the cargo airlines might have been right about this, obviously this was a source of great frustration among their pilots, which we will soon see here, but no matter how the responsibility is given to show up rested for a

flight

.

It is and always has been shared between the pilot, the airline and the regulator and if any of them do not do their part well, then the result can be pilot fatigue, which is worth remembering for this story. I will be arriving at the accident flight very soon. But first I want to take a look at the two pilots involved in the story and how they spent their days before this faithful flight. The captain was 58 years old and had worked for UPS for almost 23 years. He had started his career in the military and moved on to the Regionals. and then finally to a flight engineer position on the boing 727 for the Trans world.

He now worked in that position for a while before being promoted to First Officer and interestingly, we don't know exactly how much total time he spent. had before joining, but once he joined he went back to being a flight engineer before promoting again to first officer on the Boeing 727 now, according to UPS's internal record, he then tried to promote to captain on the Boeing 757 twice in the year 2000, but

ended

up voluntarily withdrawing from both courses because he found them too overwhelming. Instead, in 2004 he moved to the Airbus a300 fleet, where he continued to fly in the correct seat for several years before finally being promoted to captain in 2009.

His total flying experience at UPS was around 6,400 hours of which 3,265 were flown. on the Airbus a300. Now another thing worth noting about the captain was that he had received four grades on a few occasions in his recurring training sessions specifically around his non-accuracy knowledge and execution. approaches, for example, had on a few occasions flown below the minimum descent altitude, among other things, but that had happened during training sessions where the goal was to train to proficiency, so it had never caused any trips. fault verification. His colleagues were very pleased. who described him as a diligent, kind and competent pilot, open to input from his colleagues, but in the month prior to this flight he had begun to complain about the list, saying that it was becoming increasingly difficult and that each time he had to fly more legs and that he doubted he had the energy to continue flying like that until he retired.

During the days prior to the accident flight, the captain, according to his wife, had been sleeping normally and before beginning his duty he had tried to take regular naps so he could change. His body rhythm changed from day shift to night shift during the night before the accident flight. His wife had dropped him off at the UPS facility in Charlotte, North Carolina, where he had then flown as a passive crew member to Louisville. Once he got there, he booked a dormitory at the UPS crew facility and took a nap for a few hours before the shift started, meaning he was probably reasonably well-rested and not very sleepy.

At the time, the first officer was 37 years old and had been flying for corporate and regional carriers before being hired by UPS as a 727 flight engineer in 2006. She quickly moved to the 757 Fleet, where she rose to First Officer and then moved on. to the 747, where she stayed for a few years and then, in 2012, she was moved back to the Airbus a300 where she had been operating since her total time was just over 4,700 hours and of those she had only flown around 400 hours on the Airbus at the time of this flight, her training records were clean and she was described as a top person with good flying skills and her captains liked flying with her, but recently she had also started complaining about the list and how he could barely keep his eyes open on Flight.

Sometimes, on one occasion in March 2013, a colleague of hers actually found her sitting face down on a table in the crew room complaining of being completely and totally exhausted before the accident flight. She had started her shift flying One Night Flight before taking a longer break and then used that break to visit a friend in Houston before returning the next day on a jump seat flight to San Antonio and resuming her duty. That duty included flying from San Antonio to Louisville late in the afternoon of August 12, where she would be crewed along with the captain. From this story now, even though she had mentioned to her husband that she had been sleeping a lot when she was visiting her friend, her use of personal electronic equipment showed that she really hadn't slept much consistently there and that pattern continued throughout After day and night as well, this means that the first officer likely had a substantial death during his sleep when his shift with the accident captain began on August 13.

The day before the accident, the two pilots met in the UPS crew room. in Louisville around 7:30 in the morning and started preparing for their flights together, everything seemed fine so they finally got off the plane, got it ready for departure and then took off for their first flight to General Downing Peoria and then the second to Chicago. Rockford, where they had their scheduled overnight stop, these lights passed without incident and they

ended

up checking into their hotel rooms around 7:30 in the morning, but already around 10:45, just 4 hours later, the first officer having breakfast in the hotel restaurant and then was active intermittently throughout the day until it was time to check in for her next duty.

She probably had a few naps during the day, but not enough to cancel out the sleep she had now. No doubt taking the captain with him, on the other hand he seemed to have rested adequately during the night stop, so he was in quite a good mood when the hotel shuttle took them to the airport around 8 and 10 p.m., the duty they had. What they had ahead of them was what is known as a split service, in which two flights would operate in the late afternoon, followed by a few hours of rest and then another flight very early in the morning.

They began again by reviewing the planning documents their dispatcher gave them. They had prepared for them and saw that there would be no major problems for at least their first two flights, decided what fuel to take and then walked to the plane and started it normally without having any idea what would soon happen and I will tell you all about it. , after this I spent weeks researching everything I could about this accident and that job would have been much more difficult if it weren't for today's sponsor, nordvpn, my entire team and I use nordvpn a lot both from its VPN feature that helps us avoid annoying GE restrictions and find better prices on everything from rental cars to flights and hotels, but also lately thanks to its excellent cybersecurity tools, Nord has become a real shield against annoying ads, annoying malware and the potential. cyber attacks that keep your online experience smooth, very free and very, very fast.

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There was plenty of time to get some sleep, so both pilots booked a room to sleep at the UPS facility to try to make the most of the rest. Now, at this point, you may be wondering what the routines at UPS actually were to avoid fatigue. mentioned that cargo airlines had been exempt from upcoming rule changes regarding crewed flights, some limitations, but that did not mean there were no rules in place; in fact, UPS had negotiated with unions over rules that were supposed to mitigate the threat of fatigue. and those rules were significantly stricter than the minimum required at the time.

A very important part of those rules was the pilot's ability to call in fatigue when he felt it was necessary and, in that case, be removed from the list immediately without questions asked. The facility was available to all pilots but there were some conditions, you see UPS had put forward something known as a sick bank where there was a certain number of days available for each pilot each year and then they would receive a bonus on top of their salary. regular. It would be paid at the end of the year based on the number of days still left in that bank.

If a pilot called in fatigued, this would be investigated by a dedicated manager and if it was found that the call was made unfairly as in If the pilot had actually rested enough to avoid fatigue but had not used it properly, then a day would be removed from that pilot search bench. This was supposed to work as a positive incentive for the pilots, but anyone who knows humans knows how fast. something like that will start to be seen as a punishment and how people will try to avoid losing that bonus any way they can. At around 02:45 on August 14, the two pilots left their sleeping quarters and began to prepare for their final flight, both of them had managed to get some sleep and now began to review the briefing material that their flight dispatcher had prepared once again. for them on the weather side - it showed a weak front that was present just north of the Birmingham Area with a low pressure gradient, meaning they could expect very light winds but also some fairly low clouds at around 400 feet.

Low clouds were slowly clearing from the south, so at the time the pilots were observing the observations, the cloud ceiling was variable. between 600 and 1100 feet, in addition to this, there was also an active notice to airman notam indicating that the main runway at the destination airport, runway 0624, would be closed for some work on runway lights between 0400 and 0500, now that the Airf flight was scheduled to arrive about 10 minutes before the runway reopened again, leaving only runway 18 available for landing. This runway was significantly shorter than the main runway, 7.99 feet instead of 11.990, and also did not have an ILS Precision approach available.

Instead, there was a localizer and an RNAV GPS non-precision approach available and with clouds as low as now. indicated that this would require presenting an additional alternative since it was very likely that the pilots would not be able to see the runway from the highest minimums of those approaches, the dispatcher who had been planning this flight was well aware of this and therefore had planned to use runway 1 18, but did not communicate directly with the crew to communicate this somewhat unusual. Under these circumstances, he felt it was up to the pilots to contact him if they had any questions and he did not want to approach and possibly insult the captain with information he thought would be obvious by the time dispatchers in the US went through training. recurring annually to keep yourplanning skills and also something known as dispatcher resource management DRM, but that training never included any pilots.

If that had been the case, the dispatcher probably would have known that we pilots always appreciate any help we can get. obtain and no operational information would be considered inappropriate or insulting and, in fact, on this occasion it seems that the pilots really missed that news about the closed runway, as some subsequent discussions in the cockpit and the fact that this whole matter It could have probably been avoided if the flight was operationally delayed by approximately 15 minutes to allow the main runway to open. It's really really tragic. In any case, the pilots now finished their preparation and then ordered fuel for the short 45-minute descent. towards Birmingham, since the first officer had flown the previous flight, the captain would now be flying, so as soon as they boarded the plane he began preparing it for departure.

The first officer walked and checked the cargo that the plane was carrying. What they were operating was a 10 year old Airbus A300 powered by two huge Pret and Whitney 4158 turbofan engines and it was in excellent condition. The pilots had ordered £34,600 of fuel and £9,250 cargo then continued to discuss the unfairness of the fact that cargo pilots would not be included in the new flight time limitations that were being negotiated as if there were second class pilots or something. so now I want to point out clearly here. that these new rules for pilots carrying passengers were not yet in effect at this time and even if they had been, these pilots would still have been legal to fly, even if they had been subject to those new rules, the captain had only had one break a little shorter. than required by the new rules a few months earlier and the first officer was within these new limits anyway, they soon received the latest documents and at time 0355 flight

1354

requested to back away from the gate and began to move towards its runway. exit. 35 just during taxiing, the discussions in the cockpit were professional and to the point and at time 0402 the captain advanced the trust levers in the cockpit and the giant airb began to accelerate down the runway, the takeoff was completely normal and they initially climbed .

Continuing straight toward 5,000 feet, in accordance with their departure clearance, they retracted the flaps and slats as planned and were soon heading to the departure frequency; The controller cleared them to climb to 10,000 feet and turn east in a radar direction before finally clearing them south. to a VR called Bowling Green, the first officer entered that VR into the flight management computer and shouted navigation available and the captain activated navigation mode. Now this mode, the navigation mode will play an important role in what will soon happen. Aircraft generally follow a predetermined flight plan that has been approved by traffic control long before the flight actually begins.

Part of the pilot's pre-flight preparation is to enter this flight plan into the flight management computer and then carefully check it and then execute it. so that it can be used in flight when a traffic control and then out of departure clears the aircraft to a specific point; In this case, Bowling Green VR, the pilot will simply select that waypoint at the top of the active flight plan and verify that it looks correct. to the navigation screen and then execute that route, as long as the aircraft's autopilot is active in navigation mode, it will turn and follow this new route and then to any waypoint behind it according to the flight plan.

Air Traffic Control will assume that the plane is following the pre-approved flight plan, so there is no need to grant further clearances unless they want to give them a shortcut, for example, and that is how air traffic control can handle thousands of flights per day because the plane is basically cruising. autonomously. Now, using that flight plan, the flight management computer will also be able to calculate when they should begin descending, for example, based on their calculated runway mass, and as long as nothing changes, we pilots will basically just have to request descent. and then manage the aircraft. speed and configuration, both lateral and vertical navigation will be done perfectly by the computer, but the FMC is not an intelligent computer and will only do exactly what it is told, so it is susceptible to something that we, the pilots, refer to , which means that if we don't program it correctly, it can start displaying all sorts of incorrect information and it's worth keeping in mind, the aircraft was eventually cleared to climb to its flight cruise level 280 and, at about the same time, the controller also told them to continue straight. to Birmingham Airport now this clearance would erase all other points the pilots had entered into their flight plan and simply replace them with a straight line to their destination airport.

For that to happen, the first officer would have entered the airport's EA . kbhm id code in the FMC and then place it at the top of the legs page as the new active Waypoint, it basically tells the plane to just fly there, but of course in reality the plane wouldn't fly to the airport in sometime. They would have to break away from this direct route and intercept an instrument approach on whatever runway they used at Birmingham and the pilots obviously knew that if you go into a direct route like this and do nothing else to trim the route into something more realistic, The plane's FMC will assume that the pilots will fly all the way until they get to the airport and then come back and fly whatever approach they have planned to add many more tracking miles to the route than they would actually fly, like I said. is a bit stupid, so the way this is usually treated, at least on my airline, is that pet monitoring will create a new waypoint that is maybe 20 nautical miles from the airport on the direct path and then will connect that new waypoint.

Whatever approach they are hoping for, obviously it will have to be monitored very closely that it is not actually the authorization that has been given to them just an estimate, but will give a much more accurate picture of what is likely to happen and therefore, will help FMC calculate a more accurate descent route, but in this case this was not done and neither pilot noticed this discrepancy on the legs page in the FMC CDU. This problem was displayed as a route discontinuity message after the kbhm point, informing the pilots that Anyway, the FMC did not know what they wanted to do after that, shortly after receiving this direct route, the first officer exited the frequency to listen to Burmingham Terminal 8's automatic reporting service and note weather and approach information 8.

This information Dad was active and said winds were calm, visibility at 10 miles with broken cloud cover at 1,000 feet and another 7,000 feet above that. He also informed the pilots that the runway 18 locator had been in use since runway 0624 was closed on The information of the runway closure apparently came as news to the pilots and the captain only commented locating 18. This only shows who probably felt a little frustrated by having to fly a much more complicated maneuver at 5:00 in the morning. The first officer also chimed in and pointed out that this was typical because they were a bit heavy and now had to land on the much shorter Runway 18 again.

This information had been available to them at the planning stage and if they had read it. They would also have known that the main runway was scheduled to open less than 15 minutes after the scheduled arrival time. Another thing I want to point out here is that even though the 80 and also some ACR messages that the crew had received showed good and a High Cloud base of around 1000 feet above the ground, the reality was actually a little different. ; There were still dozens of lower clouds present in the area, causing the cloud base to drop as much as 300 feet in some places, but at the time of this observation none.

Of them were present exactly on the runway where the cloud base was being measured, the meteorologist who had sent this weather had included this information in a special note, but due to some problems with the AAR weather format, UPS had left to include those types of notes. in the weather report sent to the plane and the same was true for the tower controller who had updated the 80s. I could have also included those kinds of side notes in the 80s if I wanted to, but there were no clear instructions on exactly what type of time that needed to be included in those types of notes, so he had simply skipped it, what all that meant was that as the captain was now beginning to prepare for the loose spotting approach, he and his colleague probably had a mental model of the climate. which was dramatically better than it actually was and that brings us to the type of approach they were now preparing to fly, as I already mentioned it was a localizer approach and as the name implies it was flown using a localizer signal like horizontal guide.

The localizer is obviously half an ILS approach, but without the vertical glide slope guidance, which means it is much more complicated to fly and provides less guidance, which is why it is considered a non-precision approach in some of my videos previous. I have explained that Non-precision instrument approaches conducted without vertical guidance can be conducted as a constant descent approach CDA or a descending approach where the safest option is CDA. A steady descent will ensure a more stabilized approach without major changes in trim and thrust. There was a need to level off between the different minimum altitudes, so this was what the crew was now preparing so that a CDA could fly with the use of vertical speed and carefully checking the distances versus the calculated altitudes or with the use of the route of vertical navigation with the aircraft.

He would be flying a pre-programmed route up to a specific altitude above the threshold and that is what the captain was planning now. He began his briefing by reviewing a non-precision special approach checklist that highlighted all the important steps, including the minimum descent altitude. MDA would use 1,200 feet in this case and then continued with how the approach was to be conducted, including all the relevant points on the instrument approach charts while the captain briefed the first officer manning the radios and was soon handed over. to the Atlanta Center controller, this new controller told them to descend to flight Level 240 at their own discretion and the first officer read that and at the same time a FedEx plane with the same call sign number FedEx

1354

appeared on the frequency and When they heard this, both pilots mentioned this potential ATC threat by mixing their call signs, this at least to me showed that they were both quite turned on at this point and well into the game, the captain began his descent at time C 432 and when They reported The controller talked about this, he actually mixed them up with the FedEx plane, so the two pilots had a little Shuckle.

Overall, the atmosphere in the cabin was pretty good at this point, then they were delivered to the Memphis control center, where they were. It was soon clear to descend further to 11,000 feet. This was also read by the first officer and after the captain selected his new altitude on the mode control panel, he said that today they are generous, they usually take it to 15 and then keep you up and this, the captain's anticipation being held aloft by ATC would soon become important after they were handed over to the Atlanta controller, who gave them the final final configuration for Birmingham 29. 96 on Mercury and once the crew had established this.

The captain asked for the approach checklist so far, this flight was performed perfectly according to UPS standard procedures, but that would soon change around s 440. The background noise on the cockpit voice recorder was heard decreasing, which is a sign that the aircraft is decelerating as it moves forward. This was happening, the captain also said "I want", which was probably said as a reminder to the first officer, since she was actually the one who should have called, she repeated it and then told the captain that she would ask for more below, which What was probably happening here was that the plane had been descending towards 11,000 feet according to its pre-programmed trajectory but as they got closer the captain began to slow down to slow the descent but also to reduce its kinetic energy speed rather than its energy. potential. altitude, we always tend to do it this wayway when ATC keeps us high, as it will allow us to get back on track by descending at a higher speed later, once a lower altitude clearance is received, the first officer asked the controller what the lowest altitude is. responded that they would need to switch to the Birmingham approach controller for that and this sort of thing happens all the time and it is very annoying to have to switch to another frequency and check when you see that you are already receiving high on the approach PA, but apart from anticipating it , there's not much else I can do anyway.

As soon as the first officer checked in with the Birmingham approach they were immediately cleared to descend 3000 feet and the controller also told them that the main runway was still closed and asked them if they wanted to continue to locator 18, the first officer responded firmly and the controller then told them to turn right 10° and join the localizer on that heading while maintaining 3,000 feet. Now here a couple of crucial things happened. First remember what I said about the importance of keeping the flight management computer up to date to ensure the most accurate information was always there. In this case, this right turn would have meant that the captain would have selected Heading mode when exiting. pilot and then turned the aircraft about 10° to the right and since the navigation mode was no longer used, this would have allowed the first officer to enter the flight management computer and select the first point on the approach as the active Waypoint and then run that she could have also extended the center line, which I won't explain how to do here, but both of these techniques are known as landmark sequencing and are absolutely crucial to getting the path right in the future. approach, but instead of doing that, the first officer began joking about how the controllers' questions about whether they wanted to proceed via the Runway 18 location were a little strange since they didn't have much choice in the matter, the captain agreed. agreement. and some general amusement ensued, but of course if they had actually read the notum they would have known that this question was probably asked because the main track would open in about 18 minutes;

In any case, this nervous conversation meant that the waypoints in the FMC were never updated or sequenced and the captain didn't notice. This in turn meant that the FMC now thought it had many more miles of tracking than it actually did and therefore began to show that the plane was well below profile but, interestingly, after the pilots stopped laughing at the silly question from ATC, the captain asked for the train to be lowered and this was very early. to do that, he then commented oh and they keep you high, which was followed by some similar comments from the first officer, they actually weren't particularly high at this point, so it's likely that already here the captain had started to get a situation defective situational. aware of their profile, it is possible that the fact that iCal's vertical profile now showed them as very low was somehow misinterpreted by the captain as very high, rather than simply based on his anticipation that ATC would leave them high, In any case, they were now descending. fast towards 3000 feet and the captain had armed localizer mode to capture the incoming signal, but if they had looked closer at their navigation screen and their FMC CDU they would have seen that the painted runway still continued towards the airport and that there were still a flight plan discontinuity written in the CDU, but this did not happen.

This was, of course, a serious omission on the part of both pilots and the attitude they were now displaying could potentially be a sign of fatigue at time 0443 and 24. Within seconds, the controller cleared the aircraft for approach and told them to descend to 2500 feet to hold until they settled on the localizer, the crew complied with that and just a few seconds later the localizer came to life and captured the aircraft's turn toward the runway from this From that moment on, they had the right to descend according to the minimum altitudes on the short approach, but that initially did not happen.

The first minimum altitude plotted was 2,300 feet to maintain to a point called Basin, but instead of setting the crew simply continued descending to their point. last authorized altitude 2,500 feet the captain asked the first office to activate the approach in the FMC if she had not already done so and she responded well, you see on the Airbus a300, you need to physically activate the approach by selecting it in the FMC in order for The path was activated and the captain was probably hoping that this would fix the problem with the strange path he was now seeing. A few seconds later, the first officer had completed the task, but since the FMC points were not yet sequenced, the path deviation symbol vertical trajectory remained fixed at the top, indicating that they were more than full scale or 400 feet below the trajectory as they descended to 3,500 feet.

The captain asked for the battens to be extended and also exclaimed, "Incredible," probably referring to what he still perceived. As she was staying high, the first officer simply agreed with a light Shuckle and then she extended the slats to him, the captain asked for flaps 15 to be extended, which the first officer also did as he handed them over to the new approach frequency. with the same controller. and as soon as they changed the frequency, the controller cleared UPS flight 1354 to land R8, which would be the last message to the crew, the captain continued to reduce the speed of the plane and ask for more flaps and at time 0 445 and 50 seconds called. so that flaps 40 and the landing checklist were completed only 5 seconds after that, it also called for the missed approach altitude of 3,800 feet to be set and setting a new altitude was important here because without that it couldn't continue descending, but since Mis's approach altitude was higher than their current altitude, nothing would now stop them from descending to the ground, the plane had now leveled off at 2500 feet and the captain must have been hoping that the vertical trajectory would soon come to life. to be able to activate route mode, but still had a strong sequence, so it continued to show maximum flight indications with no tendency to move around as they passed over Baskin Point, the captain must have understood that something was wrong, but in Instead of telling this to the first officer, he simply selected the vertical speed and now began to descend.

This was not what he had been informed and now he was effectively swooping and flying on a descending approach instead of the reported CDA. He initially selected a 700 foot descent. per minute, which would have been pretty good, but it soon increased to 1000 feet per minute. Instead, he was still mumbling about being kept high. The first officer had already completed the landing checklist and noted that they were flying at vertical speed and not partly as reported, so she said, "Let's see, you're at vertical speed." Okay, the captain replied: yes, I'm going to do vertical speed. Yes, it kept us high.

All of these comments show a captain who was unreasonably concerned about the 200 feet above profile. were actually here and the fact that they were actually so high not because of ATC but because I had not descended to the appropriate minimum altitude those comments just don't sit well with me, I think it is much more likely that he had in fact misinterpreted the vertical profile stated as extremely high instead of what it actually said extremely low. It's very difficult to know why an experienced captain would make such a mistake, but it's possible that stay-high expectancy bias coupled with the effects of flying in the middle of the circadian low window could be an explanation.

In any case, this idea Erroneous was proven even more when a few seconds later he said and we are like very high or higher, the first officer who obviously did not suffer the same illusion. He responded about a couple hundred feet to which the captain responded yes, but that didn't reduce his descent speed, it increased it to about 1,500 feet per minute, now he did yell, okay, so in 3.3 we should be at 1380, which indicated that it was lightly monitoring the altitude. Here, located 3.3 thousand away, was the Point IM toy that had a restriction of 1380 feet and the aircraft would cross that altitude almost exactly after that they could descend to their minimum descent. altitude of 1,200 feet, which was about 600 feet above the ground, while the first officer was setting the approach altitude M on the mode control panel and then when they passed 1,530 feet, she correctly said there was 1,000 feet check instrument cross, there were no flags indicating they were now 1,000,000 feet above the ground, the captain responded with uh, okay, uh, The Da is 1,200, showing that he knew this was the next difficult altitude, but do you remember what else had been reported to be about 1,000 feet above the ground, yes?

From the bottom of the clouds, it is very likely that the crew was now waiting to start breaking out of the clouds and seeing the runway, but what they didn't know was that a layer of lower clouds had moved over the final approach obscuring the view. . to a much lower altitude, we can't know for sure, but it is likely that both pilots began scanning through their cockpit windows for the runway through the still-dense clouds as the plane descended at 1,500 feet per minute, a much higher speed. and the highest vertical speed approved for a stabilized approach below 1000 feet in the UPS manuals it was clearly stated that 1000 feet per minute was the highest speed allowed under normal unreported circumstances and if the speed was greater than that then he turned around. mandatory anyway, it was now up to the first officer to announce approaching lows and lows as they approached the 1200 foot MDA, but those calls were never made, instead he said they wouldn't be real, which can be interpreted as her referring to the actual meteorological conditions the instrument was actually inside and that would further corroborate the idea that she was probably looking out at this point there was now an automatic call for both 500 feet and the minima provided by Airbus for the air300 would, if they were installed, I made these calls anyway, but UPS had chosen to disable that feature in their fleet.

Now obviously the captain was the flight pilot and therefore in charge of managing the flight path, so when he passed through MDA without a runway in sight, he should have turned around or at least it leveled off even without any call, but that didn't happen either because the plane was now well below the MDA and had the correct profile and was still descending. The captain soon announced 2 miles, which strangely indicated that he must have been monitoring. at least some of his instruments here, but just 13 seconds later the gpws system issued its first warning signal, this was followed almost immediately by the captain muttering there, indicating that he now probably saw the runway and what he saw must have been Absolutely terrifying.

At this point it was at a height of only about 250 feet above the ground over a mile away from the runway, so the four poies must have been glowing bright red here, indicating how low they were. The captain responded by immediately reducing the vertical speed to 600 feet per minute, which was obviously still too much, and then shouted oh, I've made it to the runway. 12:00 to which the first officer responded, uh, I have the runway in sight, uh, the captain now also said that he would disconnect the pilot from the outside. but unfortunately it was too late, 2 seconds after this the pilot out warning was heard and this was followed almost immediately by the first sound of impact as the wings and AF portion of the plane crashed into trees and power lines in its path. .

It was immediately followed by a gpws warning of terrain too low which arrived late because the plane was so close to the airport at this point that the gpws warning envelope had been reduced to avoid nuisance warnings which the captain yelled oh i hit something immediately followed of several even louder impact sounds as the aircraft crashed into a mound of dirt about a mile short of the threshold, the impact cutting the aircraft into several different pieces, with the cockpit and nose severely compressed and the aart almost immediately burst into flames in the tower, the controller had not received any warning about the plane's terrible situation.

Instead, at time 0 447 and 41 seconds he could see a huge fireball rising into the low clouds at the other end of the airport and although he saw this, it took him over 1 minute to press the crash alarm and that happened because the control screen had a different layout between theday shift and the night shift and therefore initially could not even find the button after that there was an initial telephone confusion between all the rescue teams involved, where the rescue leader did not even realize that it had already been An accident occurred, but the initial confusion was quickly resolved and the fire services quickly reached the wreckage, but unfortunately were unable to do anything.

Both pilots had died in the pure impact forces, the investigation concluded that the probable cause of this accident was the pilot's continuation of an unstabilized approach and his failure to monitor the altitude of his aircraft, which led to them descending below of the minimum descent altitude and then to the terrain. The reasons why this happened included all of the The factors I already mentioned in this video and the research led to several important recommendations, which I will include on my website, which you can find a link to below, but the most important lessons that emerged from this included greater collaboration. training around the area of ​​fatigue both among regulators, airlines and pilot unions, this was to ensure that everyone involved understood the reporting systems and preventative measures and that their use was not strictly punitive.

It was discovered that the first officer had been suffering from a large sleep debt mainly because he had not used his scheduled rest time efficiently and this probably had a large effect on his performance; It is very important that we realize that fatigue can affect us in a very negative way. and that the responsibility for dealing with fatigue is shared among everyone, including ourselves, other results of this included a stronger call to make constant descent approaches mandatory for commercial airliners and more information being sent to pilots about warning of lower gpws on market margins when near an Airbus airport.

I was also told to improve the cockpit warnings when the FMC is not set correctly and to make those robocalls standard and not an option now. If you have any more questions about this or want anything clarified, please consider joining my patreon team. We can talk about this directly with me in our next Hangout and there is a link you can use to sign up somewhere here on the screen or in the description below. Have an absolutely fantastic day and see you next time, bye.