UPS Flight 1354

A cargo arrival before dawn

UPS flight 1354 left Louisville, Kentucky, at about 04:03 CDT on 14 August 2013, bound for Birmingham, Alabama. The Airbus A300-600 cargo aircraft, registered N155UP, carried the captain and first officer. The captain was flying and the first officer was monitoring. The aircraft had been built in 2004, and its estimated landing weight and center of gravity were within limits. Its maintenance records contained no unresolved discrepancies.

Birmingham's longer runway, 06/24, was closed from 04:00 to 05:00 for runway lighting maintenance. The flight's scheduled arrival at 04:51 fell within that closure. Runway 18 remained available, with a localizer approach that supplied lateral guidance. The crew planned to obtain vertical guidance from the aircraft's flight management computer. The longer runway had an instrument landing system precision approach and was due to reopen shortly after the scheduled arrival.

The dispatcher included the runway closure in the flight paperwork but did not discuss the limited approach options, low forecast ceiling or reopening time with the pilots. An erroneous nighttime restriction printed on the localizer chart led him to believe that only the RNAV GPS approach was available. The NTSB found that a discussion would have helped the crew evaluate holding for the longer runway or diverting to Atlanta. Jeppesen corrected the chart restriction after the accident.

The approach was loaded but the route remained

After listening to Birmingham's airport information broadcast, the pilots discussed the runway closure and the localizer approach to runway 18. Between 04:23 and 04:30, the captain briefed a profile approach with a decision altitude of 1,200 ft above mean sea level. The first officer entered the approach into the flight management computer. With a correctly sequenced route, profile mode could follow a computed glidepath toward the runway.

At 04:42:05, the controller vectored the aircraft to join the localizer. At this point the approach sequence should have been updated to contain the waypoints the aircraft would actually fly. The previous direct-to-KBHM navigation leg remained in the computer, together with a flight plan discontinuity before the approach waypoints. The captain did not call for verification of the sequence, and the first officer did not complete that verification.

The localizer captured and the aircraft became aligned with the extended runway centerline. Its vertical guidance still depended on the incorrect route. The computer calculated the glidepath using the total length of the navigation legs, including the unwanted direct leg, producing an unrealistically high path. The vertical deviation indicator stayed at the top of its scale. Investigators identified several other cues to the route problem, including an unusual line on the navigation display and KBHM remaining the next waypoint. The crew continued discussing the approach and their belief that air traffic control had kept them high.

A faster descent and an unbriefed change

The aircraft approached BASKN, the final approach fix, at 2,500 ft. That was 200 ft above the published minimum crossing altitude. UPS guidance recommended descending to the crossing altitude before intercepting the profile path. The NTSB found that this small excess altitude could have been corrected with minimal effort. The autopilot failed to capture the intended glidepath, and the captain selected vertical-speed mode to command the descent.

He did not brief the first officer about the change. At 04:46:24.7, shortly after completing the Before Landing checklist, she recognized that vertical-speed mode was in use. The captain increased the selected descent rate through approximately 700 and 1,000 ft per minute to 1,500 ft per minute. The investigation found that changing the approach in this way increased the first officer's workload and reduced the time available for her monitoring duties.

The originally briefed profile approach used 1,200 ft as the point to continue landing with the required visual reference or begin a missed approach. A step-down approach required the aircraft to level at the 1,200 ft minimum descent altitude until the visual conditions for further descent were met. The captain continued referring to a decision altitude. Investigators could not determine his precise intention after selecting vertical speed. His actions produced a descent that required close monitoring of the step-down altitudes and a level-off at minimum altitude.

Minimum altitude passed in cloud

At 04:47:03, with the aircraft at about 1,530 ft, the first officer made the required 1,000 ft above-airport-elevation callout. The descent continued at 1,500 ft per minute. UPS stabilized approach criteria limited the rate to 1,000 ft per minute below 1,000 ft above ground. The NTSB found that the excessive descent rate made the approach unstabilized and required a go-around.

The aircraft passed the IMTOY step-down fix near its prescribed 1,380 ft altitude, then continued downward. The first officer missed the approaching-minimums callout at 1,300 ft and the minimums callout at 1,200 ft. The captain did not arrest the descent. Both pilots had referred to the 1,200 ft minimum, but their monitoring failed as the aircraft approached and passed it.

The airport information broadcast described a broken ceiling at 1,000 ft above ground. The underlying weather observation included remarks giving a variable ceiling between 600 and 1,300 ft, which the broadcast omitted. UPS's weather system also removed remarks from dispatch paperwork and airborne weather messages. The NTSB found that incomplete weather information contributed to the crew's expectation that they would see the runway at 1,000 ft above ground. Low cloud remained over the northern approach path, and the pilots acquired the runway only during the last seconds before the tree strike.

The caution and the impact

At 04:47:24.5, the enhanced ground proximity warning system issued a sink-rate caution at about 250 ft above the terrain. The captain began reducing the selected vertical speed about a second later. He reported the runway in sight roughly 3.5 seconds after the caution, and the first officer confirmed that she could see it. He reduced the commanded rate further, but the aircraft was still descending toward terrain well short of the runway.

At 04:47:31.5, the captain disconnected the autopilot. About a second later the cockpit recorder captured the first contact with trees. A too-low-terrain caution followed that contact. The aircraft struck more trees, a utility pole and power lines before hitting downsloping terrain in a gulley. The initial tree strike was approximately 6,387 ft north of the runway threshold. The debris field extended through the gulley and up its southern side.

Both pilots died from blunt force injuries during the impact sequence. The forward fuselage suffered severe damage underneath the cockpit, while the postcrash fire largely affected the wings and aft fuselage. Investigators recovered usable cockpit voice and flight data recordings despite heat and structural damage to the recorders. Examination of the aircraft found no preimpact structural, engine or system failure. The NTSB found that the rescue and firefighting response proceeded rapidly, although the tower's initial crash-phone call was delayed.

Monitoring, fatigue and the warning system

The NTSB identified continuation of the unstabilized approach and failure to monitor altitude as the probable cause. It also identified the incorrect computer setup, the captain's failure to communicate the changed descent method, incomplete weather information and missed minimums callouts as contributing factors. The captain's performance deficiencies were consistent with problems recorded during earlier nonprecision approach training. His errors were likely associated with fatigue, distraction or confusion.

On 4 December 2013, investigators recreated the flight management route in an A300 simulator at the UPS training facility. They entered decoded data from the accident aircraft and simulated the flight from north of Birmingham to impact. The active route still led directly to KBHM, with a discontinuity before the approach's first waypoint. Activating the approach left that discontinuity in place. The simulator showed a vertical deviation value at the display's limit. This testing, together with the downloaded computer data, supported the reconstruction of the incorrectly sequenced approach.

Investigators found that the first officer was fatigued from acute sleep loss and circadian factors. During the previous 14-hour 30-minute layover, her known activities allowed two sleep opportunities totaling about five hours and sixteen minutes. She obtained a sleep room in Louisville before the accident leg, but the accumulated sleep loss and overnight timing remained significant. She had expressed tiredness and had not called in fatigued under the company's policy. For the captain, the NTSB found that circadian fatigue may have been present. He had taken steps to obtain rest, and the investigation found adequate opportunity for sleep.

The terrain system operated according to its design. The captain's moderate response to the sink-rate caution followed the aircraft operating manual and training. The pilot training guide contained more conservative guidance calling for a go-around or terrain-avoidance maneuver in instrument conditions. The aircraft's automated minimums alert and its available 400 ft and 500 ft altitude callouts were inactive. Newer terrain-system software could have issued a caution about 6.5 seconds earlier, but the NTSB could not determine whether the pilots would have responded aggressively enough to avoid impact.

The final report and safety recommendations

The NTSB adopted its final report on 9 September 2014. Recommendations addressed fatigue briefings before overnight departures, dispatcher and pilot communication, rebriefing changes to an approach, and consistent terrain-alert guidance. The Board called for pertinent weather remarks to reach dispatchers and pilots, activation of automated minimums or altitude callouts, and clearer indications of incorrectly programmed flight management routes.

The report recorded that UPS restored weather remarks to its Lido system. Birmingham revised emergency notification procedures and installed a crash-phone system that kept other stations ringing when one person answered. The NTSB also recommended that UPS and the Independent Pilots Association review the fatigue reporting system and counsel pilots whose fatigue calls resulted in sick-bank debits. Its findings stated that the crew's schedule would have complied with Part 117 requirements if those requirements had been in force and applied to cargo operations.