AVIATION INTERNATIONAL NEWS » OCTOBER 2014
The UPS A300 crew flew a nonprecision approach to Birmingham’s Runway 18.
October 1, 2014, 4:40 AM
It could have happened to any two professional pilots flying a nonprecision approach, in darkness, into weather that turned out to be worse than they expected after a night of back-side-of-the-clock flying. But the NTSB’s September 9 hearing into the Aug. 14, 2013 crash of UPS Flight 1354, an Airbus A300-600, on approach to Birmingham, Ala. (BHM), proved that even crews flying heavy jets can lose situational awareness and get just as far behind on nonprecision approach as King Air crews, especially when a handful of other factors also come into play.
The A300 is an early semi-glass-cockpit airplane employing both a primary flight display (PFD) and a navigational display in place of the traditional mechanical attitude indicator and horizontal situation indicator (HSI). The remaining cockpit instruments are round analog displays.
The NTSB determined the probable cause to be the crew’s continuation of an unstable nonprecision approach, as well as the its failure to monitor altitude, an especially critical element in the absence of an electronic glideslope. Based upon its investigators’ findings, the NTSB developed 20 recommendations from the accident–15 directed to theFAA, two to UPS, two to the Independent Pilots Association (IPA) and one to Airbus.
About the Crew
Records showed that the captain, who had approximately 6,400 hours of flying time, 3,200 of them in the A300, had stumbled slightly during earlier training events in his career, although nothing major enough to consider him unsafe when measured against thousands of other pilots. In July 2000 he began training to upgrade to the left seat of the Boeing 757 from the right seat of the Boeing 727. He voluntarily withdrew from that training, saying he felt “overwhelmed,” and returned to the right seat of the 727. He did successfully transition to the right seat of the A300 in February 2004 and on to the left seat of that same type in May 2009.
During a September 2009 training session, he incorrectly loaded an FMS waypoint that was corrected by his first officer. During the same session, the captain “got a little behind on the [localizer] approach…started down a little late,” according to the UPScheck airman, who also indicated that he had difficulty executing a missed approach once he recognized an unstable approach. During a supervised GPS approach conducted in his early line flying, the captain was, however, marked down for “flying below minimums” and reportedly had difficulty with a crosswind landing touching down “way left of centerline.” While his upgrade was successful, recurrent training records from June 2013 showed a deficiency with nonprecision approaches when he incorrectly set the minimums bug on his altimeter.
The first officer had logged just over 4,700 hours total time (403 of them in the A300), and her records indicated only one issue during A300 initial in June 2012; it read “confusion on the mechanics of the profile mode” during a nonprecision approach, although the event was eventually conducted to a satisfactory level. Both pilots had been flying during the middle of the night, but reviews of the first officer’s personal electronic devices showed she knew she was operating with a sleep deficit on August 14 yet took no action to call in fatigued.
The Birmingham Arrival
UPS 1354 was dispatched from Louisville in the early hours of August 14, its crew unaware that the BHM weather they had received with their dispatch release was missing a forecast ceiling. At arrival time the ceiling was forecast to be 400 feet, below minimums for any nonprecision approach. For an unknown reason, UPS also removed the remarks section of the pilot’s weather data that warned of variable ceilings between 600 and 1,200 feet at arrival time. Even the BHM ATIS lacked the remarks about a variable ceiling. That the crew expected to break out of the overcast at 1,000 feet agl was only the first in an unfortunate chain of events.
The crew was aware that BHM’s longest precision approach runway, 6/24, was closed for construction that morning until 5 a.m., three minutes after the time of the accident. Upon arrival in the BHM terminal area, the captain, the pilot flying, used the autopilot to command the aircraft as ATC vectored them for the Runway 18 localizer approach, which specified a 1,200-foot minimum descent altitude (MDA). With a reported ceiling of 1,000 feet, the crew expected about a 700-foot safety margin to locate the runway when they broke out of the clouds in the darkness. Runway 18 provided minimal lighting, just traditional runway edge lights and runway end identifier lights (REIL).
Once on vectors, the Board reported, the first captain should have commanded the FMSbe switched from nav mode to approach, for proper sequencing, but he was apparently distracted by a short conversation from the first officer about other runway options and forgot. Despite a displayed “discontinuity” message, the FMS was never correctly sequenced, which left the autopilot unable to capture the approach and generate an internal glideslope to assist the crew on the way to the MDA using the more common continuous descent final approach (CDFA) method. Although the first officer verified the approach, she did not notice the non-appearance of the computer-generated glideslope that would have avoided the traditional, less stable nonprecision technique of diving for the MDA that was eventually employed.
The A300 crossed the final approach fix 200 feet high and was slowing to final approach speed when the captain became aware something was wrong and switched autopilot modes to vertical speed, first requesting a 700-fpm descent, but quickly increasing that to 1,500 fpm, in violation of UPS stabilized-approach criteria. He also did not mention the mode change to the first officer, who was occupied with the before-landing checklist. Thirty-nine seconds before impact, the captain mentioned that the airplane was “way high,” although in actuality it was not.
The enhanced ground proximity warning system (EGPWS) on UPS’s A300 fleet, while technically compliant, did not operate exactly the same way as the systems aboard otherUPS aircraft. The industry standard “500” foot callout was disabled, as were the final 100-foot increments and even the “minimums” callout. The A300 system also did not include a free Airbus update that would have offered the crew an earlier alert 6.5 seconds before the crew heard their first warning. During the approach, the first officer made the required “1,000” foot call but failed to make any other callouts, including when the aircraft reached the MDA.
The A300 passed the imtoy fix–two miles from the end of the runway–at close to the correct 1,380-foot prescribed altitude, but still descending at 1,500 fpm. The aircraft passed through minimums with no callout from the first officer, who also did not mention the high rate of descent. At about 300 feet above the ground, the EGPWS called out “sink rate,” after which the captain reduced the vertical speed to 400 fpm. At about this same time, the aircraft broke out of the clouds, later estimated at 350 feet agl, rather than the 1,000 the crew expected. As both pilots called the runway in sight, the captain disconnected the autopilot just one second before the aircraft struck the first line of trees north of the airport. The CVR continued for nine more seconds and recorded a “too low, terrain” warning one second after initial impact.
If Only …
During the September 9 Q & A session, NTSB member Robert Sumwalt commented on the more current EGPWS software upgrade that Airbus encouraged operators to install. “If a newer software version had been available it would have sounded 6.5 seconds earlier and 150 feet higher. But with the excessive rate of descent, I’m not sure this would have prevented the accident. [But] it would have given the crew the opportunity to avoid this crash.” Also mentioning a 2010 IATA-published safety article about ground prox, Sumwalt said, “To get the most CFIT risk reduction possible, the airlines need to give GPS position direct to the EGPWS unit, which UPS did not do, and to keep the latest software and database up to date, which UPS did not do.”
Sumwalt said the system’s TSO requires the 500-foot callout be installed, but not that it be activated. “That’s like requiring seatbelts in cars, but not requiring people to use them,” he said. “Everything UPS does is about efficiency, with people running around with stopwatches and clipboards in case an airplane is a minute late. The sad thing is that we have a layer of defense that could possibly have prevented this accident. If you’re interested in efficiency, I can guarantee you those August 14 packages did not get delivered by 10:30 a.m.”
AIN asked UPS to comment on Sumwalt’s position that the A300 EGPWS software does not include all of the latest updates. UPS responded, “Our ground proximity system wasFAA-compliant. It’s also important to understand that the NTSB could not determine if a newer version of the software would have made a difference. Going forward, however, we are upgrading this system. While we can’t know if it would have made a difference this time, it could in a future incident.”
The company also commented that it is implementing a series of safety enhancements in response to issues raised by the investigation.
UPS Safety Enhancements
• training and standards enhancements on automation, callouts, pilot monitoring duties, stabilized approaches and no-fault go-arounds
• enhanced meteorological information available to crewmembers
• adoption of ICAO’s LOSA (Line Operations Safety Audit) program
• new standards for flying into Birmingham in darkness
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