MEC&F Expert Engineers : NTSB Releases First–Ever Video Companion to Accident Report

Tuesday, June 2, 2015

NTSB Releases First–Ever Video Companion to Accident Report



​WASHINGTON, DC

The National Transportation Safety Board today released an 8-minute video that focuses on the key lessons that pilots can learn from the investigation of a UPS cargo plane crash in Birmingham, Ala., in August 2013.

The video is a first-ever such companion to an official NTSB report. The Board plans to produce other videos in the future on major accidents.

“People consume information and absorb lessons in different ways,” said NTSB Chairman Christopher A. Hart. “This video is another way to reach pilots and aviation safety professionals with the lessons we learned through our investigative work.” 

The video is aimed at commercial and other professional pilots, but many of the lessons of the accident apply to every pilot – for example, avoiding unstable approaches.

The video can be viewed here (note - we are getting a message that the video has been removed): https://youtu.be/ubrGwanOEvM

The full report can be read here: 

Crash During a Nighttime Nonprecision Instrument Approach to Landing, UPS Flight 1354

Executive Summary

On August 14, 2013, about 0447 central daylight time (CDT), UPS flight 1354, an Airbus A300-600, N155UP, crashed short of runway 18 during a localizer nonprecision approach to runway 18 at Birmingham-Shuttlesworth International Airport (BHM), Birmingham, Alabama. 
 
The captain and first officer were fatally injured, and the airplane was destroyed by impact forces and postcrash fire. The scheduled cargo flight was operating under the provisions of 14 Code of Federal Regulations Part 121 on an instrument flight rules flight plan, and dark night visual flight rules conditions prevailed at the airport; variable instrument meteorological conditions with a variable ceiling were present north of the airport on the approach course at the time of the accident. 
 
The flight originated from Louisville International Airport-Standiford Field, Louisville, Kentucky, about 0503 eastern daylight time.
 
A notice to airmen in effect at the time of the accident indicated that runway 06/24, the longest runway available at the airport and the one with a precision approach, would be closed from 0400 to 0500 CDT. 
 
Because the flight's scheduled arrival time was 0451, only the shorter runway 18 with a nonprecision approach was available to the crew. Forecasted weather at BHM indicated that the low ceilings upon arrival required an alternate airport, but the dispatcher did not discuss the low ceilings, the single-approach option to the airport, or the reopening of runway 06/24 about 0500 with the flight crew
 
Further, during the flight, information about variable ceilings at the airport was not provided to the flight crew.
 
NTSB Companion video to UPS 1354 Report 
(note - we are getting a message that the video has been removed)

Probable Cause

The National Transportation Safety Board determines that the probable cause of this accident was the flight crew's continuation of an unstabilized approach and their failure to monitor the aircraft's altitude during the approach, which led to an inadvertent descent below the minimum approach altitude and subsequently into terrain. 
 
Contributing to the accident were (1) the flight crew's failure to properly configure and verify the flight management computer for the profile approach; (2) the captain's failure to communicate his intentions to the first officer once it became apparent the vertical profile was not captured; (3) the flight crew's expectation that they would break out of the clouds at 1,000 feet above ground level due to incomplete weather information; (4) the first officer's failure to make the required minimums callouts; (5) the captain's performance deficiencies likely due to factors including, but not limited to, fatigue, distraction, or confusion, consistent with performance deficiencies exhibited during training; and (6) the first officer's fatigue due to acute sleep loss resulting from her ineffective off-duty time management and circadian factors.


http://www.ntsb.gov/investigations/AccidentReports/Pages/AAR1402.aspx