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Fatal Error! How UPS Flight 1354 Ended in Disaster

Mentour Pilot・2 minutes read

Cargo pilots face challenges, especially at night, with recent discussions on pilot flight time limitations in the US in early 2010s focusing on passenger but not cargo pilots. Despite good rest, a fatal crash occurred due to crew errors in managing altitude during the approach, highlighting the importance of monitoring vital flight parameters.

Insights

  • Cargo pilots, like the captain in this case, face unique challenges such as night operations and potential fatigue issues, despite not being subject to the same strict flight time limitations as passenger pilots.
  • The fatal crash was a result of the crew's failure to monitor altitude adequately, descending below the minimum descent altitude due to issues with the Flight Management Computer and failing to update the FMC during the approach, ultimately leading to the tragic outcome.

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Recent questions

  • What challenges do cargo pilots face?

    Cargo pilots face challenges, especially with most operations occurring at night, which can lead to fatigue and potential safety issues.

  • What were the new pilot flight time limitations in 2012?

    In January 2012, new pilot flight time limitations were published in the US, stricter for passenger pilots but not for cargo pilots, sparking debates on safety concerns.

  • Who is responsible for ensuring pilots are well-rested before flights?

    The responsibility for ensuring pilots are well-rested before flights lies with the pilot, airline, and regulator to maintain safety standards and prevent fatigue-related incidents.

  • What factors contributed to the fatal crash?

    The fatal crash was influenced by the crew's failure to monitor altitude, descending below the minimum descent altitude due to issues with the flight management computer and incorrect path indications.

  • How did the crew prepare for the approach to Birmingham Airport?

    The crew prepared for a localizer non-precision approach, focusing on a constant descent approach (CDA) to ensure a stabilized approach, but faced challenges with updating the flight management computer and monitoring altitude correctly.

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Summary

00:00

Challenges of Night Cargo Pilot Operations

  • Being a cargo pilot involves challenges, especially with most operations occurring at night.
  • In the early 2010s, the US debated pilot flight time limitations, with new rules published in January 2012, stricter for passenger pilots but not for cargo pilots.
  • The responsibility for being well-rested before a flight lies with the pilot, airline, and regulator.
  • The captain, aged 58, had extensive experience with UPS, starting as a flight engineer and eventually becoming a captain on the Airbus a300.
  • The captain had received poor grades in training sessions but was described as competent and diligent by colleagues.
  • The first officer, aged 37, had experience with various aircraft before joining UPS and had recently complained about fatigue.
  • Before the accident flight, the captain had rested well, while the first officer had a substantial sleep debt.
  • The pilots met in Louisville, prepared for their flights, and had uneventful flights to Peoria and Chicago Rockford.
  • Both pilots had a break in Louisville before their final flight to Birmingham Shuttlesworth airport, where they faced challenges due to a closed runway.
  • The captain flew the final leg, and the aircraft, an Airbus a300, was well-maintained, with discussions on the unfairness of cargo pilots not being included in new flight time limitations.

14:55

Flight 1354: Crew Errors in Approach Planning

  • Captain and first officer were operating under new rest rules, with the captain having slightly less rest than required previously.
  • At 03:55, Flight 1354 requested push back from the gate and taxied towards Runway 35 right.
  • During taxi, cockpit discussions were professional, and at 04:02, the captain advanced the trust levers, initiating takeoff.
  • The aircraft climbed normally to 5,000 ft, retracted flaps and slats, and headed towards Bowling Green VR.
  • The flight management computer (FMC) plays a crucial role in following pre-approved flight plans autonomously.
  • The crew was cleared to climb to flight level 280 and proceed straight towards Birmingham Airport.
  • The crew failed to adjust the flight plan for a direct routing to Birmingham, leading to potential issues with the FMC.
  • Weather information from the Birmingham automatic terminal information service differed from actual conditions, impacting the crew's mental model.
  • The crew prepared for a localizer non-precision approach, focusing on a constant descent approach (CDA) to ensure a stabilized approach.
  • As the aircraft descended towards 3,000 ft, the crew failed to update the FMC, leading to incorrect path indications and potential issues during the approach.

29:06

Fatal Crash Due to Altitude Monitoring Failure

  • At 04:43 and 24 seconds, the controller cleared the aircraft for approach, instructing them to descend to 2,500 ft until established on the localizer.
  • The crew followed the instructions, with the localizer capturing a few seconds later, turning the aircraft towards the runway.
  • Despite the charted minimum altitude being 2,300 ft until a point called Basin, the crew continued descending to their last cleared altitude of 2,500 ft.
  • The captain asked the first officer to activate the approach in the FMC, necessary in the Airbus A300 to engage the path mode.
  • The crew faced issues with the vertical path deviation symbol remaining pegged at the top, indicating they were below the path.
  • As they descended, the captain requested slats and flaps to be extended, preparing for landing.
  • The captain called for flaps 40 and the landing checklist to be completed, ensuring the missed approach altitude of 3,800 ft was set.
  • The crew's failure to monitor altitude led to descending below the minimum descent altitude, resulting in a fatal crash.
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