Executive Summary
This report highlights the underlying reasons for the 2013 UPS flight 1354 crash at Birmingham-Shuttlesworth International Airport, Alabama. The accident happened when the flight crew failed to manage the aircraft during descent. It fell short of the runway during a non-precision landing approach and crashed at the end of the landing strip. All members of the flight crew were killed and the aircraft destroyed. Investigations revealed that the pilots were partly to blame for the accident because they did not pay attention to the jet’s altitude during descent, despite their continued use of an unstabilized landing approach. Furthermore, they had incomplete weather information and were fatigued. These errors led to the inadvertent descent of the plane below the recommended landing altitude and the eventual crash.
Events Leading to the Accident
On 14 August 2013, a UPS flight 1354 crashed at Birmingham-Shuttlesworth International Airport at 0447 Central Daylight Time (CDT) in Birmingham, Alabama, with two people on board. The aircraft was an Airbus A300-600, and it was registered as N155UP (National Transport Safety Board). Its first flight was in November 2003 and its delivery to UPS occurred four months later (Wrigley). On the day of the accident, the aircraft was carrying cargo from Louisville, Kentucky, to Birmingham, Alabama (Smith). The flight took off at 0503 Eastern Daylight Time (EDT) and was scheduled to land at 0451. The captain commandeered the plane and the first officer was monitoring flight activities. Before landing, the crew had contacted air traffic control and was granted permission to land on a shorter runway, as opposed to the standard longer one because of ongoing maintenance activities (Smith). Seconds before the crash, the aircraft’s ground proximity warning sounded two alarms informing the flight crew that the plane was descending too rapidly (Wrigley). Three seconds after the alarm went off, the first officer reported to have seen the runway. A few seconds later, the aircraft started crashing into trees (Wrigley). The ground proximity warning sounded the last alarm that the terrain was too low and thereafter the impact occurred. The fuselage broke apart and the nose of the aircraft stopped about 200 yards from the point of impact (Wrigley).
Causal and contributing factors
According to the National Transport Safety Board, the UPS flight 1354 crash was caused by the following underlying reasons:
- Pilot error;
- Air traffic control failed to warn pilots about the low hanging clouds around the airport. Therefore, the crew failed to receive vital information about variable forecasts;
- Air traffic control failed to notify the pilots about the single-approach option available for landing because of the closure of one of its runways.
Contributing Factors:
- At the time of the crash, night visual flight rules were in effect;
- Variable instrument meteorological conditions and ceilings were activated at the time of the incident;
- Runway (06/24), which was the ideal landing platform for the aircraft, was closed at the time of landing (from 0400 to 0500 CDT) for maintenance (Smith);
- Runway 18, where the accident happened, did not have a precision approach to landing;
- Aircraft controllers did not notify the crew about the shutdown of runway 06/24, which would have been the safest landing strip for the pilots, or that the single-approach option was the only available option for touchdown (National Transport Safety Board).
HFACS (7.0) Analysis
Unsafe Acts
Performance-based Errors
The flight crew failed to make the minimum callouts.
The crew’s performance deficiencies were consistent with those of fatigued, confused, or distracted pilots. In line with this observation, it was confirmed that the first officer suffered from fatigue due to acute sleep loss and improper off-duty time management (Smith).
Procedures not followed correctly – Flight crew failed to reconfigure the flight management computer that would aid them in landing (Wrigley).
Judgment
Decision-making Errors
Poor communication between the pilot and first officer made it difficult to detect procedural issues, which could have averted the crash (National Transport Safety Board).
Preconditions
Weather
The flight crew misjudged the altitude needed to break through the clouds because of incomplete weather information. Indeed, the pilots believed that they would penetrate cloud cover at an altitude of 1,000 feet, while in reality it was 350 feet (Wrigley).
Flight Crew’s State
The captain of the flight was off duty between the 5th and 12th of August, 2013, and he took measures to mitigate the effects of fatigue by napping at home and in a sleeping room in Louisville, Kentucky (Wrigley).
The first officer was off-duty between the 10th and 12th of August but took few measures to mitigate her fatigue. For example, on August 12, she returned to duty with a 9-hour sleep deficiency. One day later, she had an opportunity of 5.5 hours of sleep, which she did not take as well (Wrigley).
Organizational Influences
Resource Problems
The pilots felt overworked and fatigued because of tight work schedules (Smith).
Supervisory Factors
Policy and Procedural Issues
UPS failed to update the software on the aircraft’s flight control system that would have warned the pilots about their flying altitude a few seconds earlier than it did (Wrigley).
Analysis and Conclusion (Connections among HFAC’s Elements)
The UPS flight 1354 crash was caused by a number of pilot errors, which made it difficult for the flight crew to control the aircraft. The NTSB investigation revealed that the officers flew the aircraft normally until they started making mistakes at the last point of descent when they were supposed to perform the standard set of landing procedures (National Transport Safety Board). Particularly, the failure of the pilots to take a series of actions, such as monitoring altitude before the crash, made it difficult to avoid a ground impact. This problem could have been compounded by fatigue because the pilots did not get adequate sleep the night before the flight. Indeed, while waiting for clearance for take-off, the flight crew discussed their level of fatigue and the effects of UPS’s tight work schedules on their morale (Wrigley). Consequently, the National Transport Safety Board believed that the pilots were aware of their fatigued state, which could have contributed to their poor handling of landing procedures. Additionally, research revealed that the crash happened during the “circadian low,” which is the lowest point of performance for a fatigued person (Wrigley). Low body temperatures, reduced concentration or alertness, and poor performance characterize it (Wrigley).
The pilots’ insistence on landing using an unstabilized approach, while having incomplete weather information, also contributed to the crash. Particularly, it was risky to continue with the unstabilized approach because it gave the flight crew information about how much to the left or right the aircraft was but no data on vertical inclinations. This reason was further compounded by the short runway they were landing on because the standard one was closed for maintenance. Inadequate weather information also made it difficult for the pilots to know the extent of cloud cover around the airport, which would have guided their descent. The information available to them was that the cloud cover at the airport was about 1,000 feet but UPS did not update the remarks associated with this information on their flight manual (Wrigley). Consequently, the pilots could have assumed that they were flying at high altitude but the cloud cover was only about 350 feet above the ground (Wrigley). This meant that there were low hanging clouds, which may have obscured their view of the runway. Coupled with the assumption that they were flying at high altitude, the pilots could have overlooked warning signs notifying them of a fast ground approach.
Although there were concerns that the plane’s ground warning system could have failed to inform the flight crew about the impending crash on time, investigations revealed that the system worked as designed (National Transport Safety Board). However, a software upgrade could have given an additional warning to the pilots about the dangerous descent at least 6.5 seconds before impact, or 150 feet above the runway level (Wrigley). Nonetheless, considering the rapid rate of descent for the aircraft, it is debatable whether the pilots had enough time to avert the impact. Additionally, their failure to monitor the aircraft’s altitude and a possible miscommunication of their actions were also probable causes of the crash. In fact, at a critical point during the landing process, the captain could have discontinued the unstabilized approach and turned around for a safer landing but this did not happen.
Recommendations: Changes made After the Incident
Recommendations
- For a long time, cargo pilots have been treated differently from those commandeering passenger planes because they have different rules work schedules (Smith). There needs to be a review of this policy to standardize training and administrative procedures.
- UPS needs to hire more pilots to reduce workload. This recommendation would help to minimize the level of fatigue that some pilots exhibit after flying multiple hours. The recommendation is integral to the future running of airlines because pilot errors attributed to fatigue did not only cause the UPS flight crash but also those of other airlines, such as the 2009 American commuter plane crash, which killed everyone on board (Prokopovič). Another incident involving pilot fatigue was an Air Canada crash, which led to 16 injuries (Prokopovič). Additional research shows that when pilots land planes when fatigued, or at odd times of the day, the risk of making a mistake is significantly higher than a “normal” landing (Prokopovič). For example, a pilot that lands a plane at 0500 hours is similar to one who is attempting the same approach with a 0.08% alcohol level in their blood (Prokopovič).
Changes made in response to the crash
- Based on the view that the ground warning system could have notified the pilots about the rapid descent earlier than it did, there is a need to conduct periodic software updates to avert future calamities. Indeed, a ground warning system is only reliable if there are timely software updates. These recommendations would improve the level of UPS’ preparedness for future flight operations.
Works Cited
National Transport Safety Board. Crash during a Nighttime Nonprecision Instrument Approach to Landing, UPS Flight 1354. NTSB, 2019. Web.
Prokopovič, Karolina. Pilot Fatigue: A Matter Threatening Aviation Safety? Aviation Voice, 2017. Web.
Smith, Mike. NTSB: Pilots’ Errors Ultimately Caused UPS Flight 1354 Crash, Contributing Factors Cited. Advance Local, 2019. Web.
Wrigley, Sylvia. UPS 1354 and the Unforgiving Nature of Flight. Fear of Landing, 2018. Web.