NTSB: pilot error, fatigue kills


The fatal crash of UPS flight 1354 on 14 August last year which killed the two pilots was the result of an unstabilised approach into Birmingham-Shuttlesworth International Airport in Birmingham (US).

The US government’s National Transportation Safety Board (NTSB) also determined that the crew failed to monitor their altitude and 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 UPS Airbus A300-600, crashed in a field short of runway 18 in Birmingham at 04.47h. The flight originated from UPS’ hub in Louisville, Kentucky (US).

“An unstabilised approach is a less safe approach,” says NTSB acting chairman, Christopher Hart. “When an approach is unstable, there is no shame in playing it safe by going around and trying again.”

Because the flight management computer was not programmed properly, the autopilot was not able to fly the desired flight path to runway 18. The captain, without informing the first officer, also changed the autopilot mode and descended at a rate that violated UPS’ stabilised approach criteria once the aircraft descended below 1,000 feet (304.8 metres) above the airport.

As a result of the accident investigation, the NTSB has made a number of recommendations. These include 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.


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